336413288-10-9-2024-18-AS-VMIN-D9VVET-20241009162253

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336413288
Report Date: 10/09/2024
Date Signed: 10/09/2024 04:23:03 PM

Document Has Been Signed on 10/09/2024 04:23 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:	SUNNYMEAD HOME CARE		FACILITY NUMBER:	336413288
ADMINISTRATOR:	D./E. BOMBONGAN		FACILITY TYPE:	740
ADDRESS:	10625 ASTER LEAF LN		TELEPHONE:	(951) 488-1540
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92557
CAPACITY:	6	CENSUS: 4	DATE:	10/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	ADMINISTRATOR, D.E. BOMBONGAN		TIME COMPLETED:	04:28 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	On October 09, 2024, Licensing Program Analyst (LPA), Venus Mixson, made an unannounced visit to the facility for the purpose of conducting the Required Annual inspection, and met with Administrator, Aleli Bombongan, introduced herself and stated the purpose for the visit. The facility file review was conducted in the RO and additional records were requested and reviewed on site. Infection Control: LPA Mixson observed the hand washing stations in the facility restrooms. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures. PHYSICAL PLANT: Facility is licensed for six Elderly Adults and is operating at four Elderly Adults which is within the conditions and limitations of the license. Outdoor and indoor passageways are kept free of obstruction and clutter. No pool or body of water were observed on the property. According to staff, there are no known weapons kept in the home. Disinfectants, cleaning solutions, and poisons were inaccessible to residents in care. Temperature -was within in regulations for this time of day and the season. There was sufficient lighting throughout the facility and the Hot water tested within regulations at 105. degrees F and was logged. Fire extinguisher located in dining area, and next to the kitchen area has proper inspection tag. The smoke and carbon monoxide alarms were in the green and last inspected on 09/23/2024, By Redline Fire Protection Services in Colton. The interior and exterior areas of the home were observed to be clean and organized. FOOD SERVICE: Menus were posted and available for review. There was a variety of food types and were sealed and stored in a safe and healthful manner. Food supply of nonperishable and perishable foods was sufficient. The kitchen was observed to be clean, neat, and organized. LPA observed the required two-day supply of perishable and seven-day supply of non-perishable food items.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus Mixson	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

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: SUNNYMEAD HOME CARE	FACILITY NUMBER: 336413288
	VISIT DATE: 10/09/2024

NARRATIVE

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Care & Supervision/Administration: Adequate staffs are present for the supervision of residents in care. Floor plans, telephone numbers and personal rights were found posted in the facility, along with the Ombudsman's postings. The listed Administrator possesses a current administrator certificate with an expiration date of 10/23/2025.

Records Reviewed and Resident/Staff Files: LPA reviewed two staff files and reviewed the facility's staff schedule. Staff have criminal clearance and updated training along with First Aid Certification current until July 20, 2025. Four resident files were reviewed and possessed required paperwork and current TB test at the time of this review.

MEDICATION: Medications were reviewed and medications were labeled and maintained in compliance with label instructions and State and Federal laws. Medications were observed to be safe, locked, and inaccessible to residents in care. Medications and medication documentation was observed to be well organized and monitored with no discrepancies observed at this time.

Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan as well as disaster training binder. LPA observed the last fire drill met the department standards and was logged and posted on 09/10/2024, four staff were present, and the Licensee conducted the training Dominador Bombongan.

There were no observable deficiencies observed or cited per Title 22, Division 6 of the California Code of Regulations during this Annual visit.

An exit interview was conducted where a copy of this report was discussed and given to Administrator, Aleli Bombongan.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus Mixson	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC809 (FAS) - (06/04)

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