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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600794
Report Date: 07/22/2024
Date Signed: 07/22/2024 03:29:32 PM


Document Has Been Signed on 07/22/2024 03:29 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:SUNNYHILL GUEST HOMEFACILITY NUMBER:
374600794
ADMINISTRATOR:BELLA D. MARGATEFACILITY TYPE:
740
ADDRESS:1530 HILLCREST LANETELEPHONE:
(760) 723-0985
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY:6CENSUS: 6DATE:
07/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Mary Rose Delos SantosTIME COMPLETED:
03:40 PM
NARRATIVE
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On 7/22/24 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility for the purpose of conducting a 1 year required visit. LPA met with Caregiver Mary Rose Delos Santos and explained the purpose of the visit. At the time of the visit there were (2) staff and (6) residents present. The facility is licensed to serve 6 non ambulatory senior residents. The facility has an approved hospice waiver for (2). There are currently (0) residents receiving hospice services. LPA was informed that the facility will be undergoing a change of ownership. The facility administrator was unavailable during LPAs visit to verify the status.

LPA toured the facility interior and exterior of the facility. LPA observed the facility to be clean and in good repair. The facility is maintained at a cool and comfortable temperature. There are no known guns or ammunition, or pools or bodies of water on the premises. All outdoor and indoor passageways are free of obstruction. Food prep and storage areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables.

The medications are centrally stored medication in a locked closet by the dining area. The facility has seven (7) dual fire and carbon monoxide detectors, 1 central alarm for the outside, they were tested and observed to be operable. The facility was observed to have the required postings. However there was no proof of liability insurance available for LPAto review. Deficiency cited.

LPA conducted a review of (3) resident and (3) staff records/files. LPA observed for the files to have the required documentation such as a medical assessment, appraisal, and admission agreement. Regarding the staff files all staff present were observed to have obtained criminal record clearance and to be associated to the facility. The administrator Bella Margate does possess a valid administrator certificate. LPA observed Staff # 1, Staff #2 and Staff # 3 to all have expired Cardio Pulmonary Resuscitation (CPR). Deficiency cited.

SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SUNNYHILL GUEST HOME
FACILITY NUMBER: 374600794
VISIT DATE: 07/22/2024
NARRATIVE
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In addition LPA conducted a facility file review prior to conducting the visit and observed for the facility to have not paid their annual fees that were due on or before 07/01/24. As of today 7/22/24 the current amount due is $742.00. Deficiency cited.

A review of the facilities emergency disaster drills that the facility is not conducting the drills on a quarterly basis, as the last documented drill is noted to have occurred on 6/3/23. Deficiency cited.

Based on today's inspection deficiencies were cited on the attached 809D, in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted where a copy of this report, appeal rights, LIC9098-Proof of Corrections form, and LIC 811-Confidential names list was provided to Maryrose Delos Santos.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 07/22/2024 03:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: SUNNYHILL GUEST HOME
FACILITY NUMBER: 374600794

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 3 out of 3 times, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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The Licensee agrees to enroll S1, S2, and S3 in CPR training, on or before by 5pm on 7/23/24. Staff are required to complete the training on the date signed up for. Proof of correction is to be submitted to the department by 5pm on the due date indicated.
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 3 out of 3 times which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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The Licensee agrees to conduct and document an emergency disaster drill on or before by 5pm on 7/23/24. Proof of correction is to be submitted to the department by 5pm on the due date indicated.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 07/22/2024 03:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: SUNNYHILL GUEST HOME
FACILITY NUMBER: 374600794

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records review, the licensee did not comply with the section cited above in 1 out of 1 time which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2024
Plan of Correction
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The Licensee agrees to submit proof of liability insurance as described above. Proof of correction is to be submitted to the department by 5pm on the due date indicated.
Type B
Section Cited
HSC
1569.185


This requirement is not met as evidenced by:
An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. Health and Safety Code section 1569.185 provides: (a) An application fee adjusted by facility and capacity shall be charged by the department for the issuance of a license to operate a residential care facility for the elderly. After initial licensure, a fee shall be charged by the department annually on each anniversary of the effective date of the license.
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 1 out of 1 time which poses a potential health, safety or personal rights risk to persons in care, as the facility could be closed failure to pay the required fees.
POC Due Date: 08/06/2024
Plan of Correction
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The Licensee agrees to pay the annual fees on or before by 5pm on 8/6/24. Proof of correction is to be submitted to the department by 5pm on the due date indicated.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4