331800436-12-30-2024-18-AS-YDEO-DCFU8V-20241230142207

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800436
Report Date: 12/30/2024
Date Signed: 12/30/2024 02:22:26 PM

Document Has Been Signed on 12/30/2024 02:22 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 SUNRISE		FACILITY NUMBER:	331800436
ADMINISTRATOR/ DIRECTOR:	RUSSELL, JOHN		FACILITY TYPE:	740
ADDRESS:	79150 BUFF BAY COURT		TELEPHONE:	(909) 496-4636
CITY:	BERMUDAS DUNES	STATE: CA	ZIP CODE:	92203
CAPACITY: 3	TOTAL ENROLLED CHILDREN: 0	CENSUS: 1	DATE:	12/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	John Russell, Licensee		TIME VISIT/ INSPECTION COMPLETED:	02:35 PM

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) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by Licensee and granted entry. LPA began inspection with introduction, visit purpose and provided the Licensee with LPA identification and business card. Resident record review began- One (1) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 125.0 degrees F and warning labels are posted. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the laundry room. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location. Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are not clean. LPA began review of employee records- One (1) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification-no current training's, and administrator certification has expired . CPR and requirements have not been met. (Continued on next page)

Jazmond D Harris	TELEPHONE: (951) 248-0318
Yolanda Delgado	TELEPHONE: (951) 203-2990
	DATE: 12/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: JOHN RUSSELL SUNRISE	FACILITY NUMBER: 331800436
	VISIT DATE: 12/30/2024

NARRATIVE

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(Continued from Page 1)

The facility employs enough staff to meet the needs of the clients in care. Administrator certification that was provided expired on 12/27/2020, LPA contacted the RO and was advised Administrator certificate expired on 12/27/2024.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors were tested and to be operational and carbon monoxide detector is not present. Fire extinguishers are tested or replaced annually and were last done so on 12/2024. The facility is conducting emergency disaster drills however no documentation was available to corroborate.

LPA allocated time to prepare this report for delivery.

Based on the information received during this visit today, there are six (6) deficiencies with Civil penalties for $500 that is being cited per Title 22, Division 6 of The California Code of Regulations.

This report, LIC809D, LIC421IM and Appeal Rights was reviewed with and a copy provided to the facility representative at the time of the exit interview.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/30/2024 02:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 SUNRISE	FACILITY NUMBER: 331800436
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in no carbon monoxide dectector was observed which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/31/2024
	Plan of Correction
1 2 3 4	Licensee will obtain and install a carbon monoxide and email receipt/picture of carbon monoxide installed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Jazmond D Harris	TELEPHONE: (951) 248-0318
Yolanda Delgado	TELEPHONE: (951) 203-2990
	DATE: 12/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/30/2024 02:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 SUNRISE	FACILITY NUMBER: 331800436
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Infection Control Requirements

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in no Infection Control plan on file and not available to reviewwhich poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/27/2025
	Plan of Correction
1 2 3 4	Licensee will develop a plan and email LPA a copy by POC due date.

Section Cited

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in broken exterior window and two pilots on stove are not working which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/27/2025
	Plan of Correction
1 2 3 4	Licensee will repair broken exterior window and two pilots on stove and email pictures to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Jazmond D Harris	TELEPHONE: (951) 248-0318
Yolanda Delgado	TELEPHONE: (951) 203-2990
	DATE: 12/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/30/2024 02:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 SUNRISE	FACILITY NUMBER: 331800436
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in kitchen floor and counters were dirty, resident's personal bathroom was dirty which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/27/2025
	Plan of Correction
1 2 3 4	Licensee will ensure areas noted to be cleaned at all times and will email pictures to LPA by POC due date.

Section Cited

Personnel Records

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in Administrator does not possess a current certificate, expired on 12/27/2024, no process has been initiated by Adminstrator which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/27/2025
	Plan of Correction
1 2 3 4	Administrator will renewal Administrator certificate and send proof of documentation to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Jazmond D Harris	TELEPHONE: (951) 248-0318
Yolanda Delgado	TELEPHONE: (951) 203-2990
	DATE: 12/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/30/2024 02:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 SUNRISE	FACILITY NUMBER: 331800436
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in no documentation was available to review for quarterly drills which poses/posed a potential health, safety or personal rights risk to persons in care,.
	POC Due Date: 01/27/2025
	Plan of Correction
1 2 3 4	Licensee will document quarterly drills, and email a plan to ensure drills are being conducted with a schedule of 2025 dates to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Jazmond D Harris	TELEPHONE: (951) 248-0318
Yolanda Delgado	TELEPHONE: (951) 203-2990
	DATE: 12/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

LIC809 (FAS) - (06/04)

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