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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604217
Report Date: 09/22/2023
Date Signed: 09/22/2023 11:57:27 AM

Document Has Been Signed on 09/22/2023 11:57 AM - 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SUNSET ARFFACILITY NUMBER:
374604217
ADMINISTRATOR:DOST, LEENAFACILITY TYPE:
735
ADDRESS:1105 CAMINO DEL SOLTELEPHONE:
(760) 877-5773
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY: 4CENSUS: 3DATE:
09/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Leena Dost, AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility for the purpose of an annual review. LPA was greeted by Caregiver, Gabriela Hernandez and explained the purpose of the visit. Administrator Leena Dost arrived a few minutes later. A tour of the facility was conducted inside and out. At the time of visit, there were three (3) clients home and one staff was available. Administrator informed LPA that one (1) client was currently volunteering at a community senior citizen center in San Marco. The home is approved for four (4) ambulatory adults ages 18 to 59 years of age.

The facility is a three (3) bedroom two (2) bathroom one story home. Two bedrooms are shared, two clients to a room. The third bedroom is reserved for live-in staff. LPA conducted interviews with staff and clients.

During the tour the following was observed: Clients bedrooms had the required furnishings and were observed to be in good condition. Bathrooms had required signage, hand rails, non-slip mats. Night-lights were observed in the hallways. Fixtures and furniture for an operational facility are present and in good repair. All passageways were free of obstructions, charged fire extinguishers and the fire alarm system was operable, medications are kept centralized and locked, hazardous items are kept inaccessible clients. Hot water was tested at 108.5 degrees Fahrenheit. Backyard area is free from obstructions. Indoor temperature was 72 degrees.

Kitchen/Food Service: LPA observed the entire kitchen, food is stored properly and dishes are clean and in good condition. There is a sufficient supply of perishable and non-perishable foods. Area was observed to be clean and functional.

Cont'd on LIC 809C....
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2023
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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SUNSET ARF
FACILITY NUMBER: 374604217
VISIT DATE: 09/22/2023
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Cont'd from LIC 809....

Care & Supervision: Facility has sufficient care staff employed.

Administration: Emergency exiting plans, telephone numbers and Ombudsman information and other required signage are posted throughout the facility. Drills are conducted regularly. The last drill was conducted 8/3/2023. The Administrator's certificate expires on 8/10/2024.

Record Review and Client/Staff Files: LPA reviewed current staff and all staff have has Criminal Background Clearance, current CPR/First Aid certification, and trainings are current. Client records were reviewed and contained required documents. IPP and Physician reports are current. LPA reviewed P&I logs, records are balanced. P&I funds are kept separately from facility funds.

Medication Review: LPA reviewed medication and medication log. Residents' medications are being dispensed according to physician's orders.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.

An exit interview was conducted and a copy of this report was provided to Administrator, Leena Dost.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
LIC809 (FAS) - (06/04)
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