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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880662
Report Date: 02/05/2025
Date Signed: 02/05/2025 04:05:46 PM

Document Has Been Signed on 02/05/2025 04:05 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 - COCQUIFACILITY NUMBER:
361880662
ADMINISTRATOR/
DIRECTOR:
TAMISIN, ABIGAIL NFACILITY TYPE:
740
ADDRESS:18609 COCQUI RDTELEPHONE:
(909) 918-9800
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92307
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
02/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Abigail Tamisin, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:10 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, nightstands, 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 at 105 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 BrownTELEPHONE: (951) 202-5776
Becky MannTELEPHONE: 951-248-0306
DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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 - COCQUI
FACILITY NUMBER: 361880662
VISIT DATE: 02/05/2025
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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 and LIC809C was discussed and provided to Administrator Abigial Tamisin.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky MannTELEPHONE: 951-248-0306
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC809 (FAS) - (06/04)
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