<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424398
Report Date: 04/08/2022
Date Signed: 04/08/2022 01:54:02 PM

Document Has Been Signed on 04/08/2022 01:54 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:SUNNY HILL MANORFACILITY NUMBER:
366424398
ADMINISTRATOR:PALOMARES, GRACEFACILITY TYPE:
735
ADDRESS:4063 N. LEMONWOOD AVENUETELEPHONE:
(909) 823-3772
CITY:RIALTOSTATE: CAZIP CODE:
92377
CAPACITY: 6CENSUS: 4DATE:
04/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:52 PM
MET WITH:Grace PalomaresTIME COMPLETED:
01:58 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA arrived at the facility at 12:43 PM and rang the doorbell twice however the door was not answered. LPA phoned the facility at 12:47 PM but the call was not answered. LPA phoned Administrator at 12:48 PM but the call was not answered. LPA knocked on the door and Administrator Palomares opened but did not immediately allow LPA in the home due to Palomares needing to secure facility animals. LPA Bueno was allowed entry at 12:52PM and informed Administrator Palomares of the purpose of today's visit. Administrator verified that there are no active and/or suspected Covid-19 cases in the facility.

During the inspection, LPA Bueno and Administrator Palomares toured the facility inside and out. The facility has no bodies. The facility has charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. Outdoor and indoor passageways were kept free of obstruction. Cleaning supplies, medications, and sharps were kept in a safe and locked place. LPA observed a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. The facility menu was available for review. The client bedrooms had the required furniture and sufficient lighting. The facility had a supply of additional linen and extra hygiene items for the clients.

LPA Bueno interviewed Administrator Palomares regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPA observed appropriate postings in the facility, including COVID-19 symptoms postings and visitation policies, which were in accordance with the Department's guidelines. LPA observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE).
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2022
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 2
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: SUNNY HILL MANOR
FACILITY NUMBER: 366424398
VISIT DATE: 04/08/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

LPA Bueno observed that the facility appeared to be meeting operational requirements. LPA observed no apparent health and safety risks at the time of visit. No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to Administrator Palomares.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2