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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006411
Report Date: 01/24/2025
Date Signed: 01/24/2025 04:26:55 PM

Document Has Been Signed on 01/24/2025 04:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SUNNY VILLAFACILITY NUMBER:
306006411
ADMINISTRATOR/
DIRECTOR:		PARK, YOUNG SFACILITY TYPE:
740
ADDRESS:1857 SHEDDON STREETTELEPHONE:
(818) 437-0477
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 6CENSUS: 2DATE:
01/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Administrator Yung LeeTIME VISIT/
INSPECTION COMPLETED:
04:43 PM
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Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by Administrator (AD) Yung Lee after explaining the purpose for the visit. LPA observed that Administrator Yung Lee has a valid Administrator certificate which expires on October 1, 2026.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents with a hospice waiver for six. The facility is a two story home with three private resident bedrooms, three resident bathrooms, two of which are private, a living room, a dining room, a kitchen, a staff office, a laundry room, a courtyard patio, a casita, and an attached two car garage. The second story of the facility is for staff use only and is used for storage. LPA accompanied by the AD conducted a tour of the physical plant. On today's visit, LPA observed two residents in care, none of which are receiving hospice care, and the Administrator present. LPA observed residents relaxing in their respective bedrooms. LPA observed the See Something, Say Something poster (PUB 475) mounted on a wall in the dining room. LPA inspected all three resident bedrooms, and they were observed to be free of any hazards. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. All resident beds had clean linens and blankets. LPA observed additional linens are stored in a hallway closet. LPA inspected the three resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 107.4 and 108.2 degrees Fahrenheit. LPA observed a fire place in the living room which was adequately screened and not in operation.

LPA observed the kitchen has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. The five burner gas stove lights unassisted. LPA observed kitchen knives are stored in a locked kitchen cabinet. LPA observed the facility has a three day emergency food and water supply stored in the kitchen pantry. CONTINUED ON LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SUNNY VILLA
FACILITY NUMBER: 306006411
VISIT DATE: 01/24/2025
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A fire extinguisher is located in the kitchen, and it was observed the be charged and serviced as of September 20, 2024. LPA tested the wired smoke detectors/carbon monoxide detectors which tested operational. LPA tested the auditory alarms for both residents which tested operational. The centrally stored medication is kept in a locked hallway closet. LPA observed chemicals and toxins to be stored in a locked cabinet in the laundry room. The First Aid kit is stored in the staff office which was observed to have all the required components. The door leading to the attached two car garage is kept locked and inaccessible to resident in care. The garage is used for storage.

LPA and AD conducted a tour of the exterior portion of the facility. LPA observed the exterior portion to be clear of obstructions and hazards. LPA observed the courtyard patio to have an outdoor shaded seating area with furniture for resident use. LPA observed a fire place in the courtyard patio which was observed to be adequately fenced and not in operation. LPA observed a shaded outdoor seating area with furniture for resident use in the backyard. LPA inspected the casita located in the backyard. The casita is for staff use only and is kept inaccessible to residents in care. The perimeter gate on the eastside of the facility is self-latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPA reviewed the two resident files. All the required documentation were present and current in the resident files reviewed. The facility handles medications for only one resident in care. LPA reviewed the one residents’ medication and medication records. LPA reviewed one staff files. All staff present are background cleared and associated to the facility.

Based on today's observations, there are no deficiencies being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Yung Lee and a copy of the report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC809 (FAS) - (06/04)
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