<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006300
Report Date: 03/22/2023
Date Signed: 03/22/2023 09:00:39 AM

Document Has Been Signed on 03/22/2023 09:00 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:SUNRISE OF ORANGEFACILITY NUMBER:
306006300
ADMINISTRATOR:JACOBS, KELLYFACILITY TYPE:
740
ADDRESS:1301 E LINCOLN AVENUETELEPHONE:
(710) 450-4645
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY: 139CENSUS: DATE:
03/22/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Tina Tayebeh BagheriTIME COMPLETED:
08:57 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Facility Type: Residential Care Facility for the Elderly
Application Type: Initial
Capacity: 139
Census (if any clients in care): 0
COMP II Participants: Tina Tayebeh Bagheri
Interview Method: Telephone interview
On March 22, 2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.
During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restricted/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Jude De La Concepcion
LICENSING EVALUATOR NAME: Bethany Hunter
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1