371881362-10-3-2022-18-AS-CNWE-CJUQHS-20221003121139

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 371881362
Report Date: 10/03/2022
Date Signed: 10/03/2022 12:11:51 PM

Document Has Been Signed on 10/03/2022 12:11 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
RIVERSIDE, CA 92507

FACILITY NAME:	GOLDEN SUNSET VILLA LIVING		FACILITY NUMBER:	371881362
ADMINISTRATOR:	LU, MARK		FACILITY TYPE:	740
ADDRESS:	1995 SUNSET DRIVE		TELEPHONE:	(858) 397-8381
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92025
CAPACITY:	6	CENSUS: 6	DATE:	10/03/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:57 AM
MET WITH:	Mark Lu and Marisa Lu, Applicants		TIME COMPLETED:	12:20 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), Chinwe Nwogene conducted an announced pre-licensing inspection to the facility. LPA Nwogene met with Applicants, Mark Lu and Marisa Lu and toured the facility. There are currently six (6) residents in care due to a change of ownership. Application: The application is for a Residential Care Facility for the Elderly. The fire clearance has been granted for six (6) non-ambulatory residents, of which one (1) may be bedridden. Buildings and Grounds: The home is composed with living room, kitchen and dining room combination, six (6) clients bedrooms, 3 restrooms, a staff room, laundry room, backyard, and a garage. The interior/exterior walkways of the home were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors were tested and operable. There are no pools or other bodies of water located at the home. According to Mark, there are no weapons stored in the home. Rooms, furniture, beds, mattresses are all in good repair. The bedrooms are furnished and privacy is available. The dining and living room areas/furniture are clutter free and in good condition. Bathrooms were observed to have non-slip mats available. The hot water was tested and measured at 119 degrees Fahrenheit which is within regulatory limits. Outdoor areas had sufficient room for activities. A washing machine and dryer are available and in working order. Central heating and air conditioning system installed with a central panel located in hallway to control entire house. Storage and Supplies: Medications will be stored in a locked cabinet in the dinning, inaccessible to any unauthorized individuals. Secured areas are available for facility files and resident files. The first aid kit was observed to be available and complete. Cleaning supplies will be stored away in the laundry room, inaccessible to clients, washing machine and dryer are all in good repair and sufficient for approved census. A Fire extinguisher was available and fully charged. CONTINUE ON LIC809-C

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022

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
RIVERSIDE, CA 92507

FACILITY NAME: GOLDEN SUNSET VILLA LIVING	FACILITY NUMBER: 371881362
	VISIT DATE: 10/03/2022

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

CONTINUED FROM LIC809

Activities: Inside and outside, there are areas for residents to use for their leisure. Backyard is in good condition with a covered patio to provide shade over the outside table and chairs. Activity supplies are present inside the home, including television, magazines, and games.

Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. Sharps will be stored in a locked kitchen drawer, available only to authorized individuals. Trash can has tight-fitting lid. Dishwasher will be used to clean and sanitize dishes. All need appliances were present and shown to be in working condition and clean. The fridge was measured at 35 degrees Fahrenheit and Freezer was measures at -9 degrees Fahrenheit.

Forms: The following signs were observed to be posted at the home: Emergency Disaster Plan (LIC 610E), Theft and Loss Policies, Visitors Policy, Personal Rights, rights of resident council, a Facility Sketch (LIC 999), Labor Law Information, and Complaint Information.

Component III was completed during today's visit and a copy was given to Mark Lu for future reference.

LPA Nwogene will inform the Centralized Applications Bureau (CAB) that the home is ready for licensure. and Applicant will be notified of the license approval.

An exit interview was conducted were this report was discussed with and provided to Mark Lu.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2