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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801625
Report Date: 03/04/2022
Date Signed: 03/04/2022 05:03:33 PM

Document Has Been Signed on 03/04/2022 05:03 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:
03/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Juliana AnosTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required - 1 Year Continuation inspection at the facility today. This is a continuation from the 11/03/2021 Required - 1 Year inspection. Today, the LPA met with Administrator Julie Anos and explained the reason for the inspection.

At 1:00 PM the LPA began record review of ten resident files and five staff files. File review of 10 resident files revealed one (1) resident, Resident #1 (R1), out of ten (10) files reviewed was missing TB results. Resident file review also revealed, one resident, Resident #2 (R2) out of ten (10) files reviewed were missing the second page of their medical assessment. Resident files reviewed were otherwise complete. Staff file review revealed, one staff, Staff #1 (S1) out of five staff were missing a physical with TB results. Staff files reviewed were otherwise complete.

At 2:46 PM, the LPA and the Administrator reviewed medications which are centrally stored in a locked office upstairs. The LPA observed the centrally stored medications records for all residents to be incomplete as the start date of the use of the residents prescription medications is not documented in the centrally stored medication records. Therefore, the LPA was unable to determine if medications are being self-administered as prescribed. First aid supplies were observed to be complete.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview and report reviewed with the Administrator. A copy of the report will be emailed.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 03/04/2022 05:03 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 03/04/2022 at 03:04 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: 03/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2022
Section Cited
CCR
80069(c)(1)

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80069 Client Medical Assessment c) The medical assessment shall include the following:
(1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
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The administrator shall submit proof R1 has a TB test with results to CCL by 3/18/2022.
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Based on record review, the licensee did not comply with the section cites above as one resident (R1) out of 10 residents did not have TB results in file which poses a potential health risk to residents in care.
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Type B
03/18/2022
Section Cited
CCR80070(a)

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80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
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The administrator shall submit a written memo of understanding regarding keeping complete medication records and submit to CCL by 03/11/2022.

The administrator shall also submit proof R2 has a completed physical to CCL by 3/18/2022.
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Based on record review the licensee failed to comply with the section cited above as one resident (R2) out of 10 residents was missing the 2nd page to their medical assessment and all residents are missing the start date of their prescription medication which poses a potential health, safety, and personal rights 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: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/04/2022 05:03 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 03/04/2022 at 03:20 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: 03/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2022
Section Cited
CCR
80065(g)(1)

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80065 Personnel Requirements (g)
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.
This requirement is not met as evidenced:
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The Administrator shall submit S1 has a physical with TB test results to CCL by 03/18/22.
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Based on record review, the licensee failed to comply with the section cited above as one staff (S1) out of five staff was missing a physical with TB results which poses a potential health 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: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022


LIC809 (FAS) - (06/04)
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