374604337-12-28-2023-08-AS-SMAZ-CYXT9K-20231228133203

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604337
Report Date: 12/28/2023
Date Signed: 12/28/2023 01:32:09 PM

Document Has Been Signed on 12/28/2023 01:32 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	SUNSET RESIDENTIAL CARE		FACILITY NUMBER:	374604337
ADMINISTRATOR:	LOPEZ, YANET PUENTES		FACILITY TYPE:	740
ADDRESS:	6893 RADCLIFFE DR		TELEPHONE:	(702) 303-2317
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92122
CAPACITY:	6	CENSUS: 3	DATE:	12/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Licensee Yanet Puentes, and Caregiver Elena Razo		TIME COMPLETED:	01:45 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) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA introduced himself and discussed the purpose of the visit with Caregiver Elena Razo. Licensee Yanet Puentes arrived during the visit and assisted the LPA. The facility was licensed for a capacity of six (6), approved for six (6) non-ambulatory residents, and a hospice waiver of four (4). At the time of the visit the facility had a census of three (3). The LPA toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstructions and slip hazards. Resident bedrooms contained the required furnishings, including personal storage space and linens. There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, and stored in a locked area. No pools or bodies of water on the premises. Per staff, no firearms, nor ammunition were kept at the facility. Carbon Monoxide, fire extinguisher(s), and required licensing postings were observed in visible areas. LPA interviewed staff and reviewed multiple staff and resident records. Some of the required records were not present at the time of the visit. These deficiencies were cited an LIC 809D and a plan of correction was jointly formulated with the Administrator. An exit interview was conducted with licensee Puentes, to whom a copy of this report, the LIC 9099D, LIC 811, and the Licensee/Appeal Rights (LIC9058), were provided.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

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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Document Has Been Signed on 12/28/2023 01:32 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SUNSET RESIDENTIAL CARE	FACILITY NUMBER: 374604337
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of records and interview, the licensee did not comply with the section cited above in Resident # 1, which posed a potential health, safety or personal rights risk to 3 of 3 persons in care.
	POC Due Date: 01/24/2024
	Plan of Correction
1 2 3 4	Licensee agreed to obtain a physician's report for Resident # 1 and submit proof to the LPA, by 1/24/24.

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of records, and interview, the licensee did not comply with the section cited above for Staff #1 which posed a potential health, safety or personal rights risk to 3 of 3 persons in care.
	POC Due Date: 01/24/2024
	Plan of Correction
1 2 3 4	Administrator agreed to have Staff # 1 trained in 1st aid, and submit proof to the LPA, by 1/24/24

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: Lizzette Tellez	TELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/28/2023 01:32 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SUNSET RESIDENTIAL CARE	FACILITY NUMBER: 374604337
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

87412 Personnel Records (a)The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of records and interview, the licensee did not comply with the section cited above in Staff # 2 which posed a potential health, safety or personal rights risk to 3 to 3 persons in care.
	POC Due Date: 01/24/2024
	Plan of Correction
1 2 3 4	Adminstrator agree to submit Staff #2 completed and required records to the LPA, by 1/24/24.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Lizzette Tellez	TELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC809 (FAS) - (06/04)

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