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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800448
Report Date: 02/11/2022
Date Signed: 02/22/2022 10:16:25 AM


Document Has Been Signed on 02/22/2022 10:16 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:SUNRISE ASSISTED LIVING AT ALTA LOMAFACILITY NUMBER:
361800448
ADMINISTRATOR:CARL CARNEYFACILITY TYPE:
740
ADDRESS:9519 BASELINE RDTELEPHONE:
(909) 941-3001
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91730
CAPACITY:77CENSUS: 60DATE:
02/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jennifer Serrano, Business Office MgrTIME COMPLETED:
11:15 AM
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On 2/11/21 Licensing Program Analyst (LPA) Shaunte Henry arrived at the facility to conduct an unannounced annual inspection with an emphasis on infection control. LPA met with Business Office Manager Jennifer Serrano, explained the nature of the inspection and was granted entry into the facility. There are currently 60 residents at the facility. As of this date, there are no positive COVID-19 cases or individuals with COVID-like symptoms present in the facility.

LPA toured the facility. There is one point of entry for routine COVID-19 symptoms screening is initiated for all visitors. Signs have been posted throughout the facility which indicates the visitor policy and proper hand washing, cough/sneeze etiquette, and social distancing practices. Facility also documents daily temperature and COVID-19 symptom checks, and any change in condition for residents. LPA observed hand sanitizer throughout the facility. LPA observed a sufficient supply of hand hygiene, cleaning and disinfecting items. LPA observed a sufficient supply of Personal Protective Equipment (PPE) that included surgical masks, N-95 masks, face shields, gloves, gowns, glasses, etc. The facility has a designated infection control person who is responsible for ensuring that the facility is compliance with infection control practices. The facility has a COVID mitigation plan in place, which outlines testing requirements, isolating/quarantining positive COVID-19 cases, proper cleaning/sanitizing/disinfecting and monitoring of individuals for COVID-like symptoms. The facility is aware that it is mandatory that Community Care Licensing (CCL) is contacted if anyone tests positive for COVID-19.

According to California Code of Regulations, Title 22, Division 6, there were no deficiencies observed or cited during this visit. This report was left with the front desk receptionist due to Jennifer Serrano conducting an new employee orientation.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2022
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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