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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425525
Report Date: 08/17/2022
Date Signed: 08/17/2022 10:49:52 AM


Document Has Been Signed on 08/17/2022 10:49 AM - 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:
08/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Crystal Tatum, NurseTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA), Jesse Gardner, conducted an unannounced visit to the facility to continue the investigation into a complaint not related to this facility #18-AS-20220802153142. LPA met with Nurse Crystal Tatum and explained the purpose of the visit, and toured the facility.

LPA interviewed Resident One (R1), and two staff members, S1, and S2. During the tour of the facility, LPA did not note any violations of Title 22. LPA received documents related to R1.

An exit interview was conducted. This report was reviewed with Executive Director Diana Salas and a copy was provided, along with a copy of the LIC811.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
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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