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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801625
Report Date: 11/03/2021
Date Signed: 11/03/2021 05:12:54 PM

Document Has Been Signed on 11/03/2021 05:12 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
CCLD Regional Office, 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: 55DATE:
11/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Julie AnosTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required - 1 Year inspection at the facility today. The LPA met with Administrator Julie Anos and explained the reason for the inspection.

At 1:06 PM the LPA conducted a physical plant tour of the facility grounds with Administrator Julie Anos to ensure there are no health and safety concerns and facility is in compliance with Title 22 Regulations.

COMMON AREA: The LPA observed the downstairs common TV room area. The smoke alarm was tested and operational. The central entry point for symptom screening for residents, staff and visitors is in this common area. Fire extinguishers observed were fully charged and last serviced 09/13/2021. RESIDENT APARTMENTS: The LPA conducted a tour of a random selection of seven resident apartments on the first and second floor. Each apartment has one to two bedrooms, a common living area, a bathroom and storage area. Bathrooms in each apartment had a supply of hand soap and hand towels. In apartment #7, at 1:13 PM the hot water temperature measured at 131 degrees F. In apartment #3 the hot water measured at 98.8 degrees F, apartment #17 74.3 degrees F, apartment #16 93 degrees F, apartment #15 91.4 degrees F, and in apartment #9 118.4 degrees F. Smoke alarms and carbon monoxide detectors were tested in each apartment. Apartment #15, bedroom A and apartment #9 bedroom B were missing smoke alarms. KITCHEN: At 2:11 PM the kitchen and dining room were observed. The facility had a sufficient supply of perishable and non-perishable foods. MEDICATIONS: Medications were locked and centrally stored in the medication room.

Due to time constraints, the LPA will return at a later date to continue the inspection. Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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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Document Has Been Signed on 11/03/2021 05:12 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 11/03/2021 at 03:28 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: 11/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2021
Section Cited
CCR
80088(e)(1)

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80088 Furniture, Fixtures, Equipment, and Supplies(e)(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water ...used by clients to attain a hot water temperature of not less than 105 degrees F .. and not more than 120 degrees F.
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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 to CCLD by 11/10/2021.
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This requirement is not met as evidenced by:
Based on observation, the licensee failed to comply with the section cited above as Apt 108's hot water temperature measured above 120 degrees F. and four apartments' hot water measured below 105 degrees F. which poses an immediate health and safety risk to residents in care.
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Type A
11/03/2021
Section Cited
CCR80020(a)

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80020 Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
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This is an immediate violation and a civil penalty is being assessed. (see LIC 421M). The administrator stated they will purchase new smoke detectors and have them installed immediately and submit proof to CCL.
Civil penalties will continue to accrue until the violation is corrected.
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Based on observation, the licensee failed to comply in the section cited above as Apt 15 and Apt 9 were missing smoke detectors which poses an immediate safety risk to residents in care.
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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:Desaree Perera
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2021


LIC809 (FAS) - (06/04)
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