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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701144
Report Date: 04/09/2024
Date Signed: 04/09/2024 03:22:00 PM

Document Has Been Signed on 04/09/2024 03:22 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SUNNI VISTA CARE HOMEFACILITY NUMBER:
342701144
ADMINISTRATOR/
DIRECTOR:
ASTRONOMO, RAEHANFACILITY TYPE:
735
ADDRESS:11013 FABER WAYTELEPHONE:
(818) 325-9999
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 4CENSUS: 4DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Raehan AstronomoTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Unannounced Annual Inspection visit was made by Licensing Program Analyst (LPA) Kimberly Viarella to this facility on 04/09/24.  LPA identified herself to the Caregiver on duty, explained the purpose of the visit, and asked to speak with the Designated Facility Administrator (DFA).  LPA met with Raehan Astrononmo and a brief interview followed.  LPA observed the DFA's certificate ( # 6023642735) and that it expires on 01/03/25.

The inspection began in the kitchen.  All knives and sharps were locked and inaccessible to residents in care. The food supply was adequate for 2-day perishable and 7-day nonperishable. Opened packages in the refrigerator were dated appropriately. 

LPA compared facility sketch with the sketch on file to ensure no alterations were made. LPA inspected the 4 resident bedrooms and 1 staff bedroom.  All resident rooms and common areas had the required furniture, furnishings and lighting to be in compliance at this time.

LPA noted soap, paper towels and trashcans in the 2 facility bathrooms. The hot water temperature was measured to ensure it was between 105 and 120 degrees Fahrenheit. The fire extinguisher was located the kitchen and was last serviced on 4/13/23 by River City Equipment Co., and was in compliance at this time.

The exterior of the building was inspected by the LPA.  There were no bodies of water present and the yard was completely fenced in.  LPA observed that all screens and gutters were in good repair.  There was also a covered patio area with outdoor furniture for residents to enjoy.

The LPA observed medications were stored in a large locked cabinet in the kitchen and inaccessible to residents in care. Medications were primarily the pill packs provided by the pharmacy. Medications that required refrigeration were stored in a locked box in the refrigerator. LPA reviewed storage, dosing, and
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SUNNI VISTA CARE HOME
FACILITY NUMBER: 342701144
VISIT DATE: 04/09/2024
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destruction procedures. A review of the First Aid kit by the LPA found it to be complete and in compliance.

LPA completed a review of 2 staff files and they were in compliance at this time. A review of resident records
was also completed and all the necessary components were in place at this time.

LPA documented observations and provided technical assistance. According to the California Code of Regulations, Title 22, no deficiencies were cited during today's visit.

A copy of this report was provided.

Exit interview.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC809 (FAS) - (06/04)
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