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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003018
Report Date: 03/16/2023
Date Signed: 03/16/2023 04:15:37 PM


Document Has Been Signed on 03/16/2023 04:15 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 NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:SUNNY BLISSFACILITY NUMBER:
345003018
ADMINISTRATOR:ROMERO, RUSSELFACILITY TYPE:
740
ADDRESS:4604 ASHEVILLE COURTTELEPHONE:
(916) 844-7930
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
03/16/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Christine Torres, Licensee TIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced for a pre-licensing inspection due to a change in ownership. LPA spoke with caregiver, Cherry Yap, who contacted Licensee, Christine Torres, who arrived at 2:20 pm. LPA also observed caregiver Jann Yap,also present. Prior to initiating today's inspection, LPA completed required COVID-19 Department protocols and was wearing a surgical mask. LPA observed (5) residents to be resting in their rooms. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (4). Currently, there are (2) residents receiving hospice services.

LPA and Licensee toured the interior and exterior of the facility including the common areas, (5) resident bedrooms, (2) bathrooms, kitchen, and laundry area. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting throughout. Inside temperature measured as 75*F and the hot water temperature in the kitchen measured 115*F. LPA observed sufficient 7+day non-perishable and 2+ day perishable supply of food and sharps, medications and toxins were locked. LPA observed the smoke/monoxide alarms to be working, and the fire extinguisher to have been last serviced 11/8/22. LPA observed the necessary grab bars/ non-skid flooring in the bathrooms and sufficient towels, linens, personal hygiene items and PPE. LPA observed a a complete First aid kit with all required supplies. LPA observed the front and back ramps to have required hand rails, the outside gate to be unlocked from the inside and outside seating for residents. LPA reviewed (2) resident binders and (2) staff binders and found them to be organized and current. Discussed vaccination status of staff/residents and current Covid visitation protocols. LPA observed games, books and activities. Administrator certificate #6061381740- exp 2/7/24 posted and other required postings, including staff training requirements. Administrator to update resident paperwork once licensed. Facility has a call-button system with custom ring tones.
Comp III was completed as well as the Pre-Licensing Inspection Tool domains.
Pre-Licensing is complete and this facility has no deficiencies. LPA to notify CAB the pre-licensing inspection has been conducted.
Exit interview. Copy of report left with Licensee.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023
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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