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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604119
Report Date: 11/04/2024
Date Signed: 11/04/2024 12:52:22 PM

Document Has Been Signed on 11/04/2024 12:52 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:SUNRISE ARFFACILITY NUMBER:
374604119
ADMINISTRATOR/
DIRECTOR:
DOST, LEENAFACILITY TYPE:
735
ADDRESS:1260 AVENIDA AMISTADTELEPHONE:
(760) 877-5773
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY: 4CENSUS: 4DATE:
11/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:Administrator, Leena DostTIME VISIT/
INSPECTION COMPLETED:
01:00 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
On 11/4/2024, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to conduct a required annual inspection. LPA was greeted and granted entry by Caregiver, Gabriela Hernandez who was informed of the purpose of the visit. Administrator, Leena Dost arrived during the visit.

LPA toured the facility with Administrator Dost. The facility has a fire clearance for four (4) ambulatory clients and serves adults ages 18 through 59. The facility is made up a two-story home with two (2) client bedrooms, two (2) client bathrooms, a kitchen, dining room, laundry room, and attached garage. Indoor and outdoor passageways are free of obstruction. Outdoor shaded seating is available for clients in care and there were no bodies of water observed on the premises. Administrator Dost tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed two (2) charged fire extinguishers mounted in the facility that were last serviced on 5/16/2024. LPA toured the kitchen and observed the facility has a two-day supply of perishable foods and seven-day supply of non-perishable foods. Medications are secured in a locked closet near the stairs. LPA reviewed the Medication Administration Record for two (2) clients while Administrator Dost reviewed their physical medications and no discrepancies were discovered. LPA reviewed the Record of Client's/Resident's Safeguarded Cash Resources (LIC 405) for two (2) clients while Administrator Dost reviewed their physical monies and no discrepancies were discovered. Cleaning solutions and disinfectants are secured in the locked laundry room. LPA toured the garage and observed the facility has backpacks and emergency food and water for the clients in care. LPA reviewed random staff and client files. Client files reviewed had updated Individual Program Plans and signed admission agreements. One staff file reviewed had the Department's required training records and a valid CPR/first aid certification. Staff present has a criminal record clearance. LPA observed various board games and activities available for client leisure. The facility's living room fire place is adequately screened. During today's visit, LPA did not issue any citations. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator Dost.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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 1