361880661-1-10-2025-56-AS-BMAN-DCSUUA-20250110145314

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880661
Report Date: 01/10/2025
Date Signed: 01/10/2025 02:53:29 PM

Document Has Been Signed on 01/10/2025 02:53 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	SUNRISE VALLEY INC - KAMANA		FACILITY NUMBER:	361880661
ADMINISTRATOR/ DIRECTOR:	TAMISIN, ABIGAIL N		FACILITY TYPE:	740
ADDRESS:	18752 KAMANA RD		TELEPHONE:	(760) 880-2227
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92307
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	01/10/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:55 AM
MET WITH:	Abigail Tamisin, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA) Becky Mann conducted an unannounced required 1-year visit to the facility. LPA met with Abigail Tamisin, Administrator and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). Licensed capacity of 6 with a current census of 5. LPA conducted an overall inspection of the facility, which included, but was not limited to the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: beds, mattresses, night stands, storage space, and sufficient lighting. Bathrooms were clean and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature tested between 111 and 114 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. All sharps are locked. There was a designated area for resident/staff files. Overall, the facility is clean, in good repair, and operating in a safe condition for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. Dishes, cups, and utensils were also stored properly.

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

Nedra Brown	TELEPHONE: (951) 202-5776
Becky Mann	TELEPHONE: 951-248-0306
	DATE: 01/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025

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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SUNRISE VALLEY INC - KAMANA	FACILITY NUMBER: 361880661
	VISIT DATE: 01/10/2025

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Record Review: LPA reviewed (3) resident files for admission agreements, updated physician reports, and needs and services plans. Resident files are maintained and up to date. LPA reviewed (3) resident medications. Medications are labeled and administered as prescribed. Medications are kept locked and inaccessible to residents in care. LPA also reviewed (3) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Facility's staff records are up to date.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report LIC809, LIC809C, LIC9102 was discussed and provided to Administrator Abigial Tamisin.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky Mann	TELEPHONE: 951-248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2025

LIC809 (FAS) - (06/04)

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