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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801625
Report Date: 03/12/2024
Date Signed: 03/12/2024 06:38:24 PM

Document Has Been Signed on 03/12/2024 06:38 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SUNRISE MANOR, LLCFACILITY NUMBER:
565801625
ADMINISTRATOR:JULIANA ANOSFACILITY TYPE:
735
ADDRESS:441 WEST CHANNEL ISLAND BLVDTELEPHONE:
(805) 240-7600
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 60CENSUS: 48DATE:
03/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:JULIANA ANOSTIME COMPLETED:
06:45 PM
NARRATIVE
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At 10:30 a.m. Licensing Program Analysts (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA met with Administrator Julie Anos and explained the reason for the inspection.

Beginning at 10:55 AM, the LPA conducted a physical plant tour of the facility grounds with Staff Cath Hipolito to ensure there are no health and safety concerns and facility is in compliance with Title 22 Regulations.

PHYSICAL PLAN TOUR: The LPA conducted a tour of 10 random selected resident apartments on the first and second floor. The LPA also observed the downstairs common TV room area, outside patio, kitchen, dining room and medication room. Medications were locked and centrally stored in the medication room. The smoke alarms ware tested and operational. Fire extinguishers observed were fully charged and last serviced 09/13/2023. The facility had a sufficient supply of perishable and non-perishable foods. There are no bodies of water on the premises.

Resident Apartments: Each apartment has two bedrooms, a common living area, a bathroom and storage area. Bathrooms in each apartment had a supply of hand soap and paper towels.
In apartment #17, at 11:14 AM, the LPA observed a can of Presto Patch Ready-Mixed Multi Purpose Patching compound and a small stack of floor tiles in the living room. Upon observation staff stated that maintenance had left it there. At 11:29 a.m. the hot water temperature measured at 99.6 degrees F after letting the water run in excess of 10 minutes. The LPA observed a total of seven (7) mattresses without a linen cover and extremely stained in apartments #4, #8, #10, #14, and #17. The LPA also observed several pillows without pillow covers and full of stains.

Report will continue on LIC809-C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNRISE MANOR, LLC
FACILITY NUMBER: 565801625
VISIT DATE: 03/12/2024
NARRATIVE
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In apartment #15, at 11:32 a.m. the LPA observed the living room curtains unsanitary and stained and observed the heater without the screen, the screen was next to the heater. The LPA observed the storage room unsanitary with stains on the walls, a hole on the wall. In apartment #14 at 11:45 a.m. the LPA observed a closet door not installed, at 11:48 a.m. the LPA observed the wall in residents’ room with a hole next to the resident’s bed.
In apartment #12 at 12:14 p.m. the hot water temperature measured at 103.9 degrees F and the sink was plugged.
In apartment #11 at 12:21 p.m. the LPA observed closet doors, and resident’s bedroom door removed, and a room, and living room full of previous residents’ items. The room also was observed to have wires all tangled and some wires were coming from outside of the window.
The LPA observed large holes on the walls with exposed tubing in the storage rooms of apartments #3, #4, #10, and #14.
In apartment #4 at 12:47 p.m. the LPA observed the bathroom with mold and a hole on the ceiling.
In apartment #6 at 12:49 p.m. the LPA observed a bottle of OdoBan disinfectant, a bottle of LA’s Totally Cleaner with Bleach.
The LPA observed doors two doors in the outside hallway of the second floor and a toilet in the hallway of the first floor. The LPA observed various windows with an excess of dust on the edges.
The LPA observed the floors of all the bedrooms to be unsanitary with an excess of debree. Upon observation, staff stated that housekeeping was working on the cleaning of the rooms.

Interviews: During the visit the LPA conducted five (5) client interviews. No immediate concerns were voiced at this time.

Record Review: At 2:30 p.m., a review of facility files was initiated. Facility records are stored in a locked office. The LPA identified that one (1) out of five staff (S1,) did not have appropriate background clearance and not t associated to the facility. The administrator was not able to provide S1's file.

Due to time constraints the LPA will return at a later date to complete the annual.



Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 03/12/2024 06:38 PM - It Cannot Be Edited


Created By: Esther Cortez On 03/12/2024 at 05:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNRISE MANOR, LLC
FACILITY NUMBER: 565801625

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the LPA observed large holes on the walls in various apartments with exposed plumbing, mold and a hole on the ceiling in the bathroom of apartment #4, exposed wiring in apt#11, two (2) heaters with no covers, and unkempt windows and floors, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2024
Plan of Correction
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The administrator will develop a plan on how they will ensure the facility is clean, safe, sanitary and in good repair at all times, and submit plan to the LPA by 3/14/24. The plan should adress the deficiencies observed and timeline of when those will be repair.
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in as the LPA observed disinfectants in apt#6 and a can of Presto Patch Ready-Mixed Multi Purpose Patching compound in apt#17 which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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POC has been met, administrator removed all items during todays visit.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 03/12/2024 06:38 PM - It Cannot Be Edited


Created By: Esther Cortez On 03/12/2024 at 05:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNRISE MANOR, LLC
FACILITY NUMBER: 565801625

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as S1 has been working at the facility since February of 2024 without approved criminal record clearance and association to the facility which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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Administrartor agreed to have staff 1 (S1) background fingerprint cleared and associated to the facility before working in the facility and a written declaration ensuring all staff will have a background clearance and be properly associated to the facility prior to working, residing, or volunteering in the facility will be submittedl to LPA no later than 03/13/2024.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 03/12/2024 06:38 PM - It Cannot Be Edited


Created By: Esther Cortez On 03/12/2024 at 05:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNRISE MANOR, LLC
FACILITY NUMBER: 565801625

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the water temperature in two (2) resident restrooms was below 105 degrees F which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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The administrator will contact a plumber to access the water temperature issues and will submit proof a plumner came to the facility. The Administrator will also submit a five day water temperature log of the apartments with temperature issued. to CCLD on 03/22/2024.
Type B
Section Cited
CCR
85088(c)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the LPA observed seven (7) mattresses stained and without matress covers and linens, and observed various pillows stained and without pillow covers which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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The Administrator agree to inspect each apartment occupied by the residents and ensure they all have clean pillows and mattresses with appropiate pillow covers, mattresses covers and linens, and ensure the residents have extras on hand when they are washing the current ones. Administrator will submit proof to the LPA by 3/22/2024. Proof can be photos, receits of supplies purchased or self-certification letter.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 03/12/2024 06:38 PM - It Cannot Be Edited


Created By: Esther Cortez On 03/12/2024 at 05:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNRISE MANOR, LLC
FACILITY NUMBER: 565801625

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
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
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Based on record review, the licensee did not comply with the section cited above as records for S1 were not available for the LPA to inspect, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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Administrator shall make sure new staff and all staff have a completed and current personnel file. Administrator shall submit S1's documents to LPA at by 03/22/204.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


LIC809 (FAS) - (06/04)
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