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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006300
Report Date: 04/13/2023
Date Signed: 04/13/2023 11:20:36 AM

Document Has Been Signed on 04/13/2023 11:20 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SUNRISE OF ORANGEFACILITY NUMBER:
306006300
ADMINISTRATOR:BAGHERI, TINAFACILITY TYPE:
740
ADDRESS:1301 E LINCOLN AVENUETELEPHONE:
(710) 450-4645
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY: 139CENSUS: 0DATE:
04/13/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Tina BagheriTIME COMPLETED:
11:35 AM
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Licensing Program Analysts (LPAs) Sean Haddad and Dwayne Mason Jr. conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPAs met with Applicant (AP) Tina Bagheri, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 01/20/2023. This is an initial application with no residents in care.

At about 8:45AM, LPAs and AP observed the following: Structure. This is a large commercial facility. Facility has 1-building with 3 stories, 92 rooms with each room having its own bathroom, and additional common bathrooms and common areas. The memory care unit is the entire first floor and part of the third floor with delayed egress on all doors. There are 2 courtyards with patio cover for the residents, with additional terraces, with equal amounts of space allocated to memory care residents and assisted living residents. Facility telephone number is (714) 450-4645. Resident Bedrooms. The resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Lamps, chairs, linens, and storage for resident bedrooms inspected. Staff Bedrooms. There are no staff bedrooms. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 109.4 and 112.2 F degrees. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. 2 days perishable and 7 days nonperishable food supply observed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances. Stove burners, microwaves, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the utility rooms. Medication rooms are locked. First-Aid Kit & Activity Supplies: observed and available. Resident & Staff Files. This is an initial inspection and LPAs observed storage space for resident and staff files. Fire clearance was approved Orange City Fire Department on 02/02/23. Courtyards. Courtyard exit gates are operational and unlocked. Courtyards and balconies have shaded area for outdoor activities and sufficient seating for residents. Component III was completed with AP during today’s inspection. AP will obtain liability insurance once the application is approved.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SUNRISE OF ORANGE
FACILITY NUMBER: 306006300
VISIT DATE: 04/13/2023
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During the inspection, LPAs explained the process of this application and about the post licensing inspection once the facility is licensed. AP was informed today that the facility is ready for licensure and final approval will be processed by the CAB supervisor in Sacramento. An exit interview was conducted and a copy of this report was discussed with and provided to AP.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC809 (FAS) - (06/04)
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