<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802461
Report Date: 03/23/2021
Date Signed: 03/23/2021 04:13:51 PM

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 AT WOOD RANCHFACILITY NUMBER:
565802461
ADMINISTRATOR:TAMARA K BERRYFACILITY TYPE:
740
ADDRESS:190 TIERRA REJADA RDTELEPHONE:
(805) 584-8881
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:100CENSUS: 73DATE:
03/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Edith KennedyTIME COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Ashley Smith an unannounced Case Management - Incident visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted virtually via FaceTime with Administrator Edith Kennedy.

On 3/14/2021, the facility submitted a Report of Suspected Dependent Adult/Elder Abuse, which documented that on 3/13/2021, Resident #1 (R1) reported that a caregiver came into their room on 3/12/2021 and proceeded to take their clothes off. R1 reported that they were bigger than them and they could not do anything to stop the caregiver. R1 was assessed and no apparent injuries were noted or observed. On 3/22/2021, LPA Eva Miller followed up with the Administrator and obtained additional information. The Administrator submitted a Special Incident Report on 3/22/2021.

During today's visit, the LPA interviewed the Administrator at 3:22pm, conducted a virtual tour, and requested documents pertinent to the investigation. The Administrator was notified that this incident was referred to Community Care Licensing Investigation's Branch (IB) and assigned to Investigator Lorraine Patterson to interview R1. Further investigation is required before findings are delivered.

No health and safety hazards noted at this time, and no citations were issued.



Exit interview conducted. A copy of the report was issued via email for signature.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021
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 1