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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800436
Report Date: 12/20/2023
Date Signed: 12/20/2023 01:07:49 PM


Document Has Been Signed on 12/20/2023 01:07 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:JOHN RUSSELL SUNRISEFACILITY NUMBER:
331800436
ADMINISTRATOR:RUSSELL, JOHNFACILITY TYPE:
740
ADDRESS:79150 BUFF BAY COURTTELEPHONE:
(909) 496-4636
CITY:BERMUDAS DUNESSTATE: CAZIP CODE:
92203
CAPACITY:3CENSUS: 1DATE:
12/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:ADMINISTRATOR, JOHN RUSSELLTIME COMPLETED:
01:13 PM
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On December 20, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the required annual inspection and met with the Administrator, John Russell. The LPA introduced herself and stated the purpose of the visit.

LPA Mixson toured the facility along with the Administrator and inspected the facility inside and outside, and there were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is a single-story home, located in a gated community with an address of 79150 Buff Bay Court, Bermuda Dunes, CA. 92203. Physical Plant: The facility phone number is (442)666-3009 and is operable. The LPA observed the residents' bedroom, and it was equipped with required furniture as per Title 22. The LPA inspected the facility bathroom, and the hot water temperature was tested and tested within regulations. The bathroom was clean and appliances were operating appropriately at the time of this visit. The facility has a swimming pool with a locked gate. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguisher. The Administrator takes the fire extinguishers in to be refill at Desert Fire in October of 2023. The facility has the required postings such as "If you See Something, Say Something" and the "Personal Rights" postings. The cleaning supplies and sharp items were kept locked and inaccessible to the resident in care. There was a designated storage space for the resident and staff files and they were locked and inaccessible to the resident in care. The overall facility is clean, the furniture is in good condition. The facility air conditioning and other appliances were operable currently at the time of this visit. Medications: were locked and inaccessible to the resident. Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Dishes and utensils were in sufficient supply and stored properly. Care & Supervision: The facility has sufficient staff, one at the time of this visit, and one resident. Records Review: The LPA reviewed one resident file, requested one staff file, and interviewed one resident and one staff. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit. An exit interview was conducted and a copy of this report was given to the Administrator, John Russell.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
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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