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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006411
Report Date: 12/27/2023
Date Signed: 12/27/2023 09:39:16 AM


Document Has Been Signed on 12/27/2023 09:39 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 VILLAFACILITY NUMBER:
306006411
ADMINISTRATOR:PARK, YOUNG SFACILITY TYPE:
740
ADDRESS:1857 SHEDDON STREETTELEPHONE:
(818) 437-0477
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:6CENSUS: 0DATE:
12/27/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Young Park
Yung Lee		TIME COMPLETED:
09:55 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection visit to follow up on corrections identified during visit on 12/15/2023. LPA arrived at the facility and was greeted and granted entry by 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 09/01/2023. 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. Facility also has an additional dwelling unit (ADU) in the backyard, ADU is a studio with one bathroom.

At 9:00 a.m. LPA toured the facility and observed the following:

· There is now lighting in three out of three resident bedrooms, and in the activity room.

· Water temperatures tested at 111.2 degrees F.

· Facility is two-stories, and second story consists of master bedroom for staff, facility has a signal system that is audible and identifies resident’s bedroom.

· Downstairs master bedroom 3 has a chest of drawers, and chairs for residents.

· All resident beds have the required elements including blankets and bedspreads.

· Visiting policy is posted at the entrance of the facility.

· Drawers and lock on file cabinet for medication are operable.

· Five out of five gas stove burners are operable and refrigerator in garage has been removed from the facility.

All noted items from visit on 12/15/2023 have been addressed. The facility is ready to be licensed. An exit interview was conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023
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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