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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800429
Report Date: 01/24/2024
Date Signed: 01/29/2024 09:03:31 AM


Document Has Been Signed on 01/29/2024 09:03 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:SUNRISE GUEST HOUSEFACILITY NUMBER:
565800429
ADMINISTRATOR:LAIGO-RAMOS, ANNABELLE L.FACILITY TYPE:
740
ADDRESS:2383 ELMDALE AVENUETELEPHONE:
(805) 520-1051
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 6DATE:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:48 AM
MET WITH:Annabelle Laigo-RamosTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Zabel Chochian made an unannounced Required - 1 Year annual visit to this facility. Upon arrival LPA met with staff Anita and Teofilo Tan. Staff contacted Administrator Annabelle Laigo-Ramos who arrived shortly after.

A tour of the physical plant was conducted with staff at approximately 11am. LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures and Food Service. Smoke detectors and Carbon Monoxide detectors were tested and functioned properly during time of visit. Fire extinguishers were observed to be fully charged. Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident. Sufficient amount of linens observed for resident use. Signal alarms system checked functioned properly. Bathrooms: LPA observed all bathrooms properly supplied and had functional fixtures however needs to be cleaned. LPA observed grab bars and non-skid mats in all bathrooms. Sufficient amounts of supplies for personal hygiene observed. Hot water temperature measured at 119 degrees fahrenheit. Kitchen: The kitchen appeared clean; appliances and fixtures appeared functional. LPA observed a sufficient amount of two (2) day perishable and seven (7) day non-perishable food supply, properly stored. Sharp objects are stored in a locked cabinet. Common Areas: These included the two living rooms and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Surrounding Grounds (Outdoors): There is a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises.



File review conducted for all residents from approximately 1pm-4pm. Resident records were reviewed for, but not limited to: appraisals, physician report, admissions agreement, consent forms, and medication logs. Five (5) out six (6) resident medications and records reviewed with administrators.
Due to time constraints this facility annual evaluation visit will continue to another date.
Exit interview conduct. Copy of today's report provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
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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