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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424399
Report Date: 03/19/2025
Date Signed: 03/19/2025 12:04:13 PM

Document Has Been Signed on 03/19/2025 12:04 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SUNNY LANE MANORFACILITY NUMBER:
366424399
ADMINISTRATOR/
DIRECTOR:		RAMELLE LLADONESFACILITY TYPE:
735
ADDRESS:15351 KIMBALL ST.TELEPHONE:
(760) 669-0045
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 4CENSUS: 4DATE:
03/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:35 AM
MET WITH:Rustan LladonesTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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Licensing Program Analysts (LPAs) Magda Malcore and Eldin Serrano made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPAs met with Rustan Lladones, Direct Support Provider (DSP), were granted entry to the facility, and discussed the purpose for the visit. The facility is an Adult Residential Care Facility (ARF) with a license capacity of (4), and a current census of (4). The facility is an Inland Regional Center (IRC) certified vendor. During today's visit, there were no clients present. LPAs conducted a general inspection of facility, which included, but was not limited to, the following:

Operation/Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor space for client activities. The facility's outdoor activity area is enclosed with a self-latching gate. The facility is maintained at a comfortable temperature of 71 degrees F. Client bedrooms were furnished with beds, night stands, chairs, and sufficient lighting. Client bathrooms were maintained clean, fixtures were operating properly, and equipped with non-slip mats. The hot water temperatures in the bathrooms measured at 113.3 degrees F. The facility is equipped with smoke detectors and carbon monoxide alarms, fully charged fire extinguishers, laundry equipment, and telephone service. The facility has posted in a common area Community Care Licensing complaint poster, Ombudsman poster, facility license, client activities, menus, and emergency telephone numbers. Sharps and cleaning supplies were kept locked and inaccessible to clients in care. The facility staff schedule reflects 24 hours a day, 7 days a week staff coverage.

Food Service: Kitchen and dining areas were maintained cleaned. Non-perishable and perishable food supply was sufficient for number of clients care. Cups, plates, and utensils were sufficient for number of clients in care.

Health Related Services: The facility maintains record of client medications and medications were centrally store in a locked cabinet. The facility has a first aid kit with manual.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SUNNY LANE MANOR
FACILITY NUMBER: 366424399
VISIT DATE: 03/19/2025
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Record Review: client files reviewed had admissions agreements, physician’s reports, placement agreements, needs and services plans, and P&I records. Staff files reviewed had First Aid/CPR certifications, criminal record clearances, job training, and health screenings. The Administrator’s certification, facility’s insurance and emergency drill training are up to date.

No deficiencies were cited and a technical assistance was issued per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where this report (LIC809) & (LIC9102) was discussed and a copy provided to DSP Lladones at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC809 (FAS) - (06/04)
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