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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425525
Report Date: 06/20/2023
Date Signed: 06/20/2023 06:45:55 PM


Document Has Been Signed on 06/20/2023 06:45 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:SUNNY ROSE GLENFACILITY NUMBER:
336425525
ADMINISTRATOR:SHANNON JOHNSONFACILITY TYPE:
740
ADDRESS:29620 BRADLEY RDTELEPHONE:
(951) 679-3355
CITY:MENIFEESTATE: CAZIP CODE:
92586
CAPACITY:81CENSUS: 54DATE:
06/20/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
06:01 PM
MET WITH:FACILITY NURSE, Ian WesolowskiTIME COMPLETED:
06:58 PM
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On 06/20/2023, Licensing Program Analysts (LPAs), Chinwe Nwogene and Venus Mixson conducted an unannounced Health and Safety Check. LPAs met with the Facility Nurse introduced them selves and stated the purpose of the visit.

Today's visit is in response to the self reported death of Resident 1 (R1 - see LIC811 Confidential Names List). The Resident passed away at the facility, date of death: 06/17/2023

LPAs conducted a Health and Safety check at the facility, and no health or safety issues were identified. LPAs requested and received pertinent documents, and completed the Death Report.

There were no deficiencies were cited or observed on this date.

An exit interview was conducted and a copy of this report was provided to the Lead Caregiver.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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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