306006411-12-15-2023-22-AS-CGUZ-CYJQ7F-20231215105505

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006411
Report Date: 12/15/2023
Date Signed: 12/15/2023 10:55:16 AM

Document Has Been Signed on 12/15/2023 10:55 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:	SUNNY VILLA		FACILITY NUMBER:	306006411
ADMINISTRATOR:	PARK, YOUNG S		FACILITY TYPE:	740
ADDRESS:	1857 SHEDDON STREET		TELEPHONE:	(818) 437-0477
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92833
CAPACITY:	6	CENSUS: 0	DATE:	12/15/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Young Park Yung Lee		TIME COMPLETED:	11:10 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	Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with Licensee Yung Lee and designated Administrator (AD) Young Park. An application to operate a Residential Care Facility for Elderly (RCFE) for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden residents was received by CCL on 9/01/2023. Structure: The facility is a two-story house with three resident bedrooms, three bathrooms, living room, kitchen, dining area, office, laundry room, family room, and attached two car garage downstairs; upstairs is a staff bedroom with a bathroom. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the dining area. There is a backyard with an exit gate on one side of the house. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard. Resident Bedrooms Two out of three resident bedrooms had the required furnishings. One out of three resident bedrooms did not have a chest of drawers. LPA observed all beds had linens, however, three beds do not have blankets or bedspreads. LPA observed all windows were screened. Signal system There is no signal system. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored in the laundry room. Licensee will obtain a lock and key.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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: SUNNY VILLA	FACILITY NUMBER: 306006411
	VISIT DATE: 12/15/2023

NARRATIVE

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Medications, First-Aid Kit & Book:
Medication will be stored in a locked file cabinet. File cabinet was found to be inoperable. Designated AD stated it was defective and had ordered a replacement. First aid kit is stored in the dining area. The first aid kit has all the required elements.

Resident & Staff Files:
Records will be kept locked with medication.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
Fire extinguisher is fully charged.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the client’s use, stored in the living room.

Fire clearance:
Was approved by a fire inspector of Orange County Fire Authority on 10/01/2023. Special conditions noted, “Non-sprinkler. Built approx. 2004. OFC 435.8.3.4 exception.”

Bedrooms Staff:
Staff bedroom is located upstairs.

Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Hot water measured between 114.8-131.9 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

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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: SUNNY VILLA	FACILITY NUMBER: 306006411
	VISIT DATE: 12/15/2023

NARRATIVE

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Emergency Phone Numbers, Exit Plan & Menu:
Posted and available, means of exiting, emergency phone numbers and food menu.

Food Service:
A supply of 2-day perishable and 7-day of non-perishable food will be maintained on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Two out of five burners on gas stove were inoperable. Refrigerator, dish washer, and microwave in the kitchen were operable. Washer, and dryer in laundry room are also operational. Refrigerator in the garage had unlabeled food items, with some of the items leaking fluids and had a noticeable odor upon opening and closing refrigerator door, designated AD stated they would not be using that refrigerator.

Licensee to address the following corrections by 05/16/2023:

· There is no lighting in two out of three resident bedrooms, and in the activity room. All rooms must have lighting.

· Water temperatures tested at 131 degrees F in two out of three resident bathrooms. Water temperature to be adjusted to meet regulation of 105 to 120 degrees F.

· Facility is two-stories, and second story consists of master bedroom for staff, therefore facility must have a signal system.

· Downstairs master bedroom 3 does not have a chest of drawers, nor chairs for residents. Bedrooms must contain all required elements, including chest of drawers and chairs.

· Two out of two beds in master bedroom 3 do not have blankets or bedspreads and bed in bedroom one does not have a bedspread. All resident beds must have the required elements including blankets and bedspreads.

· Visiting policy is to be posted.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

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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: SUNNY VILLA	FACILITY NUMBER: 306006411
	VISIT DATE: 12/15/2023

NARRATIVE

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· Drawers on file cabinet for medication are not operable. Cabinet drawers must be operable to allow facility staff access to resident’s medication.

· Two out of five gas stove burners are inoperable and refrigerator in garage contains unlabeled food items and has a noticeable odor. Licensee to ensure facility is safe, sanitary and in good repair.

LPA will make an additional announced visit to follow-up on corrections listed above. An exit interview was conducted, and a copy of this report was provided to designated AD.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia Gutierrez	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

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