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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424398
Report Date: 03/12/2024
Date Signed: 03/13/2024 03:24:42 PM

Document Has Been Signed on 03/13/2024 03:24 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: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:
03/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Grace Palomares/AdministratorTIME COMPLETED:
12:36 PM
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Licensing Program Analyst (LPA) Bianca Wolcott and Nedra Brown (LPM) arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by Grace Palomares (Administrator) and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card. The facility has 5 client bedrooms, 1 staff office, 2 bathrooms, kitchen, dining area, living room, laundry room, attached garage, and backyard. LPA completed a walk through of the facility and review of records.

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPAs observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Water temperature measured 105 within range. Grab bar chair is present in the restroom. LPAs observed a locked cabinet under kitchen sink and locked drawer with sharps. Hallway closet with cleaning supplies and chemicals was locked.

Fire extinguishers are charged, mounted. All outdoor and indoor passageways are free of obstruction. Night lights and emergency lighting is present. A locked area is provided for medications. There is a telephone working at this location. The LIC 610E, emergency disaster plan is maintained. Emergency Drills and Fire Drills are being maintained. The facility has a current written definitive plan of operation. The facility is maintained in conformity with the regulations adopted by the state fire marshal. P&I was accessed and verified by Administrator. Refrigerator is 40 degrees, and freezer is -0 degrees.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Bianca Wolcott
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2024
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: SUNNY HILL MANOR
FACILITY NUMBER: 366424398
VISIT DATE: 03/12/2024
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Personnel Records/Training/and Staffing-. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. LPA observed First Aid Book available at facility.
Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medical and Dental- LPA reviewed resident records. Two (2) residents files & (1) staff files were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. The facility is meeting documentation requirements. Resident Rights are posted in the facility and a copy is signed on file.

Food Service- Food prep areas are clean and organized. Food supply meets the requirement of one week supply of nonperishable and 2-day supply of perishables food on hand.



LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually, last done on 04/16/23. The facility is conducting emergency disaster drills last one done 1/01/24. Fire drills were conducted on 1/01/24.


Two clients were interviewed.

This report was reviewed with and a copy provided to the facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Bianca Wolcott
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC809 (FAS) - (06/04)
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