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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800137
Report Date: 12/14/2023
Date Signed: 12/14/2023 02:29:03 PM

Document Has Been Signed on 12/14/2023 02:29 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
, CA 92507
FACILITY NAME:SUNRIDGE MANOR INCFACILITY NUMBER:
361800137
ADMINISTRATOR:LANDICHO, ROBERTFACILITY TYPE:
735
ADDRESS:6800 SUNRIDGE COURTTELEPHONE:
(626) 241-3726
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 4CENSUS: 4DATE:
12/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Licensee/Administrator Robert LandichoTIME COMPLETED:
02:40 PM
NARRATIVE
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On 12/14/2023 at 11:10 AM, Licensing Program Analyst (LPA) Melody Brown arrived unannounced to conduct the required comprehensive annual visit to the facility. LPA met with Direct Service Professional (DSP) Staff #3 (S3), introduced self and stated the purpose of the visit. Licensee/Administrator Robert Landicho was contacted and arrived during the visit.

The facility has 5 bedrooms, 2 bathrooms, kitchen, dining room, living room, and attached garage. The facility is vendorized by Inland Regional Center (IRC). LPA Brown completed a walkthrough of the facility, review of records, medication audit and P&I audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL), LPA Brown observed four (4) clients. There are no obstructions to indoor passageways, but LPA Brown observed obstruction to outdoor passageways. Deficiency will be issued. The facility is maintained at a comfortable temperature of 78 degrees Fahrenheit. LPA Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPA Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 113 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, CCL complaint poster, emergency disaster plan were posted in a common area. Sharps and medications were kept in secure cabinets inaccessible to clients. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility. Overall, the facility is clean, and operates in safe conditions for clients in care.

*** Continuation in LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: SUNRIDGE MANOR INC
FACILITY NUMBER: 361800137
VISIT DATE: 12/14/2023
NARRATIVE
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Yards/Outside: One shaded patio, one (1) side gate(s) with self-latching handle on the right side of the house that leads into the backyard, attached garage observed. The outdoor pathway on the side of the facility was not free of obstructions. Deficiency will be issued.

Food Service: LPA observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA Brown reviewed client files for admission agreements and needs and services plans and Physician Report (LIC602). LPA Brown observed that C1, C2, C3 and C4 do not have the Needs and Services Plan in their facility file. Deficiency will be issued as this pose potential health, safety and personal rights risks to clients in care. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA Brown observed that S1 has no updated Administrator Certification. Per LPA Brown’s records review, no renewal application was submitted to CCLD and S1 Administrator certificate expired 11/28/2023. Deficiency will be issued. LPA Brown reviewed C1, C2, C3 and C4 P&I records and LPA Brown observed no issue. LPA Brown reviewed C1 and C2 medications, LPA Brown observed no issue.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102 and Appeal Rights were discussed and copies were provided to Licensee/Administrator Robert Landicho.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/14/2023 02:29 PM - It Cannot Be Edited


Created By: Melody Brown On 12/14/2023 at 01:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SUNRIDGE MANOR INC
FACILITY NUMBER: 361800137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not having the outdoor side passageway free of obstruction which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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The Licensee stated to remove the obstruction in the side outdoor passageway and submit proof to LPA Brown at plan of correction (POC) due date.
Type B
Section Cited
CCR
80066(a)(12)(B)1
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having a current and valid Administrator Certificate or by not submitting the Administrator Certification Renewal packet to CCLD for renewal processing which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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The Licensee stated to submit the Administrator Certification Renewal Packet to CCLD for processing and submit proof to LPA Brown at POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/14/2023 02:29 PM - It Cannot Be Edited


Created By: Melody Brown On 12/14/2023 at 01:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SUNRIDGE MANOR INC
FACILITY NUMBER: 361800137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having the required Needs and Services Plan for Client #1 (C1), Client #2 (C2), Client #3 (C3) and Client #4 (C4) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2023
Plan of Correction
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The Licensee stated to submit a copy of completed Needs and Services Plan for C1, C2, C3 and C4 to LPA Brown at Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023


LIC809 (FAS) - (06/04)
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