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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336413288
Report Date: 10/12/2023
Date Signed: 10/12/2023 03:43:59 PM


Document Has Been Signed on 10/12/2023 03:43 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 CAREFACILITY NUMBER:
336413288
ADMINISTRATOR:D./E. BOMBONGANFACILITY TYPE:
740
ADDRESS:10625 ASTER LEAF LNTELEPHONE:
(951) 488-1540
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY:6CENSUS: 4DATE:
10/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:ADMINISTRATOR, ALELI BOMBONGANTIME COMPLETED:
03:50 PM
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On October 12, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived to the facility unannounced in order to conduct the required annual inspection, and met with the Administrator, Aleli.

LPA Mixson toured the facility, along with the Administrator, and inspected the inside and outside of the facility. There were no obstructions to indoor and/or outdoor passageways at the time of this visit. The facility is a single story home, located at 10625 Aster Lead LN Moreno Valley, CA. 92557.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). The facility phone number is (951) 488-1540, and is operable at this time. The LPA observed the resident's bedrooms, and each was equipped with required furniture; including bed & mattresses, night stands, storage space, and sufficient lighting. The LPA inspected the residents bathrooms, and the hot water temperature tested within regulations. The three bathrooms were clean and appliances were operating appropriately at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and a fire extinguisher. Posters such as; the ombudsman and CCL complaint poster were posted in a common area. The cleaning supplies, toxins, and sharps were kept inaccessible to residents in care. There was a designated storage space for resident and staff files. Medications: were reviewed, and were locked and inaccessible to the residents. The overall facility is clean, in good repair, and operating in safe conditions for residents currently at the time of this visit. Food Service: Non-perishable and perishable food supply is sufficient for number of residents, and there are a variety of food types available for the residents. Dishes and utensils were also stored properly. Care & Supervision: Facility has sufficient staff, and staff were engaging the residents during this visit. Record Review: The LPA reviewed four resident files, three staff files, and the required CCL reports from previous visits. There were no observable Title 22, Division 6 Regulation violations cited during todays visit.
An exit interview was conducted and a copy of this report, along with the LIC 811, was given to the Administrator, Aleli Bombon.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2023
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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