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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002740
Report Date: 05/25/2022
Date Signed: 05/31/2022 08:38:10 AM


Document Has Been Signed on 05/31/2022 08:38 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:SUNRISE HOMESFACILITY NUMBER:
397002740
ADMINISTRATOR:ELIZABETH ABESAFACILITY TYPE:
740
ADDRESS:8100 S. BRIGHT ROADTELEPHONE:
(209) 234-2550
CITY:FRENCH CAMPSTATE: CAZIP CODE:
95231
CAPACITY:15CENSUS: 12DATE:
05/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Elizabeth Abesa, AdministratorTIME COMPLETED:
11:45 AM
NARRATIVE
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On 05/25/2022 at 9:15 am, Licensing Program Analyst (LPA) T. White arrived unannounced to conduct a required 1-year annual inspection. LPA met with Caregiver, Amy Dolores and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 15 residents. LPA later met with Administrator, Elizabeth Abesa who holds a certificate #6010093740 that expires on 10/26/2023.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 119.1 degrees Fahrenheit. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on February 09, 2022. First aid kit was observed to be complete. LPA observed completed mitigation plan. LPA reviewed 5 resident files and 3 staff record files.

LPA observed the following deficiency:
- LPA observed Staff #3 (S3) does not have a Health Screening or TB test on file.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted with Administrator. A copy of report and Appeal Rights given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022
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 05/31/2022 08:38 AM - 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
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: 05/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents....
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documentation, the licensee did not comply with the section cited above in 87411(f). LPA observed Staff #3 (S3) does not have health screening or TB test on file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2022
Plan of Correction
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Administrator agreed to send S3's health screening and TB test to CCL by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2022
LIC809 (FAS) - (06/04)
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