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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880689
Report Date: 10/05/2023
Date Signed: 10/31/2023 02:20:45 PM

Document Has Been Signed on 10/31/2023 02:20 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
, CA 92507
FACILITY NAME:SUNRISE AT EASTVALEFACILITY NUMBER:
331880689
ADMINISTRATOR:MANIQUIS, ROXANNEFACILITY TYPE:
735
ADDRESS:7323 PRAIRIE ISLAND CIRTELEPHONE:
9097301781
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY: 4CENSUS: 4DATE:
10/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Aichiro Funtila, CaregiverTIME COMPLETED:
04:00 PM
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At approximately 1405: Licensing Program Analyst (LPA) Amy Goldenberg arrived to the facility to conduct an annual inspection. LPA was greeted at the door by a caregiver Katrina Mendoza and granted entry. LPA learned that there are one (1) caregiver and four (4) clients present during this inspection. LPA was later met by Rosario Maniquis, Administrator. Four clients and one staff interviews were conducted during this visit.

Approximately 1425- LPA began review of resident records. Four (4) 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.

Approximately 1450- LPA began review of employee records. One (1) record was reviewed. LPA reviewed employee record for first aid certification, finger print clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification.


CPR and annual training requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the residents in care. The facility administrator is present a sufficient number of hours to maintain the facility. Administrator certification is present.

Approximately 1530: LPA toured the facility inside and outside. LPA observe the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the residents.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: SUNRISE AT EASTVALE
FACILITY NUMBER: 331880689
VISIT DATE: 10/05/2023
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Lighting is sufficient for safety and comfort. Water temperature measured 114 degrees F. Grab bars, non slip mats are present in the restrooms. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the garage/laundry area. Fire extinguishers are charged, mounted and dated 07/02/2023. All outdoor and indoor passageways are free of obstruction. Night lights and emergency lighting is present. A locked area is provided for medications and sharp objects. There is a telephone working at this location. The LIC 610E, emergency disaster plan is maintained. The facility has a current written definitive plan of operation. The facility is maintained in conformity with the regulations adopted by the state fire marshal. Food prep areas are clean and organized. Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. The facility is conducting emergency disaster drills, last done on 06/24/2023
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Based on the information received during this visit today, there are no deficiencies being cited per Title 22, Division 6 of The California Code of Regulations. This report was reviewed with and a copy provided to the facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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