397002740-6-3-2021-27-AS-ABOE-C3MTPK-20210603145427

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397002740
Report Date: 06/03/2021
Date Signed: 06/03/2021 02:54:59 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	SUNRISE HOMES		FACILITY NUMBER:	397002740
ADMINISTRATOR:	ELIZABETH ABESA		FACILITY TYPE:	740
ADDRESS:	8100 S. BRIGHT ROAD		TELEPHONE:	(209) 234-2550
CITY:	FRENCH CAMP	STATE: CA	ZIP CODE:	95231
CAPACITY:	15	CENSUS: 6	DATE:	06/03/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Elizabeth Abesa		TIME COMPLETED:	03:00 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 06/03/2021 at 8:10am, Licensing Program Analyst (LPA) Ashley Boothe spoke with Administrator, Elizabeth Abesa regarding facility risk assessment questions. Administrator confirmed no staff or clients have experienced symptoms within the last 10 days. At 12:15pm LPA and Licensing Program Manager (LPM) LPM Liza King arrived unannounced to conduct a required 1-year Annual inspection. LPA and LPM met with Administrator, Elizabeth Abesa and explained the purpose of today’s inspection. LPA and LPM was allowed entry into the facility that is licensed to serve a total capacity of 15 residents of which 2 are non ambulatory and 0 Hospice in compliance with fire clearance and licensure. Three of three staff observed with criminal record clearance and associated in Licensing Information System. LPA observed Administrator Certificate expires on 10/26/2021. LPA interacted with a random number of residents during this visit. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed property, resident bedrooms, restrooms, common area, dining room, kitchen. LPA observed all required furniture in resident rooms and new flooring in good repair. The temperature inside the facility was measured at 76 F which is within the required range of 68 F and 85 F, or in areas of extreme heat the maximum shall be 30 F less than the outside temperature. The hot water was measured at 106.7 F which is not less than 105 F and not more than 120*F. LPA observed the centrally stored medications, knives, and chemicals stored in locked kitchen area inaccessible to residents. Administrator stated residents are supervised during meal times in the attach dining room. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and missing antiseptic solution.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUNRISE HOMES	FACILITY NUMBER: 397002740
	VISIT DATE: 06/03/2021

NARRATIVE

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LPA observed a fire extinguisher inspected on 2/5/2021 and 5 year inspection on suppression system conducted in May 2020, smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA observed the freezer and refrigerator with food drippings and debris with staff food comingled and unlabeled. LPA observed missing window screens in resident rooms, common area, and kitchen, two hoses unravelled on the outdoor walkway residents use, barbed wire on back property fence, and shower curtain with mold.

LPM provided recommendations to Administrator on COVID Mitigation Plan report. Updated Mitigation Plan to be submitted to LPA by 6/7/2021.

Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Facility Floor Plan/Plot Plan LIC999
Administrator Certificate
Emergency Disaster Plan LIC610E
First aid/CPR certificates
Liability Insurance

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation and any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

LIC809 (FAS) - (06/04)

Page: 2 of 13

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SUNRISE HOMES	FACILITY NUMBER: 397002740
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(c)

Maintenance and Operation

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in that LPA observed missing window screens in resident rooms, common area, and kitchen which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/02/2021
	Plan of Correction
1 2 3 4	The licensee agrees to submit proof or replacement to LPA by POC due date.

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

LIC809 (FAS) - (06/04)

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