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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701144
Report Date: 10/11/2024
Date Signed: 10/11/2024 11:09:33 AM

Document Has Been Signed on 10/11/2024 11:09 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
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: 3DATE:
10/11/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Raehan Astronomo TIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 10/11/2024, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to open a case management visit regarding the recent death of a resident, R1. LPA identified herself upon arrival, stated the purpose of the visit and asked to speak with the Designated Facility Administrator, Raehan Astronomo. The Administrator was not at the facility but staff contacted him by phone and Mr. Astronono stated he would arrive in15 minutes.

This LPA conducted a walkthrough of the facility. Currently all residents were attending day program activities. There were 2 staff present at the time of this inspection. All the living areas and the 4 resident bedrooms contained all of the required furniture, furnishings, and lighting to be in compliance at this time.

LPA requested the following:
R1's client file with R1's Admission Agreement, Emergency ID/ Contact sheet, Appraisal / Care Plan, medical information including LIC 602, medication logs for approximately August - October 2024, Any incident reports for the past year,

LPA also requested an LIC 500, a resident roster, and facility sketch.

LPA met with Raehan Astronomo briefly but due to time constraints, this LPA will return at a later date to continue this case management.

No deficiencies were observed or cited during today's visit. A copy of this report was provided and an exit interview was conducted.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2024
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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