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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606841
Report Date: 01/16/2025
Date Signed: 01/16/2025 05:07:05 PM

Document Has Been Signed on 01/16/2025 05:07 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SUNNYSIDE GUEST HOMEFACILITY NUMBER:
197606841
ADMINISTRATOR/
DIRECTOR:
RICHARD VILLAVERDEFACILITY TYPE:
740
ADDRESS:4457 N. MAXSON ROADTELEPHONE:
(626) 443-9529
CITY:EL MONTESTATE: CAZIP CODE:
91732
CAPACITY: 12CENSUS: 10DATE:
01/16/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:29 PM
MET WITH:Marissa Barajas, CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA) Noemi Galarza made unannounced case management visit regarding a self reported incident on the relocation of 2 residents. Due to mandatory evacuation orders from Fire Advisory two (2) residents were relocated to this facility. One (1) resident resided at Bedell Family Crest, The # 197601322, 3267 Fair Oaks, Altadena, CA 91001. The other resident resided at Bedell Family Circle, The, 962 East Concha Street, Altadena, CA 91001. LPA met with caregiver staff and explained the purpose of the visit to Administrator Richard Villaverde telephonically. A physical plant tour of the facility was conducted to check the health and safety of the 2 evacuee residents.

The following observations were made:
  • Both relocated residents have designated rooms with beds, bedding/linen, and hygiene supplies.
  • Both residents are ambulatory. Resident (R1) uses a cane.
  • Medication Administration Records (MARs), medications, resident file documents were reviewed.
  • Sufficient staff was observed. LIC 500 Personnel Report was not provided.
  • The facility has sufficient 2-day perishable and 7-day non perishable food supplies. T
  • The last fire drill was conducted on 10/24/2024.
  • Staff stated that it is unknown whether residents have responsible parties, and/or if they were notified.


No health and safety concerns were observed.

Exit interview was conducted with caregiver Marissa Barajas and a copy of the report was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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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