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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609684
Report Date: 08/23/2024
Date Signed: 08/30/2024 09:53:43 AM

Document Has Been Signed on 08/30/2024 09:53 AM - 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SUNNYBRAE HOMEFACILITY NUMBER:
197609684
ADMINISTRATOR/
DIRECTOR:		SAVELLA, JEFFREYFACILITY TYPE:
740
ADDRESS:8001 SUNNYBRAE AVETELEPHONE:
(323) 455-7821
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 6DATE:
08/23/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Jeffrey Savella- LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analysts (LPA) Leslie Ngo-Castaneda met with facility licensee Jeffrey Savella for a Plan Of Correction (POC) visit.

The purpose of the POC visit is to make sure deficiencies were corrected on reports issued on 8.7.2024.

Entrance interview conducted.

LPA toured the home and requested the following:

-CCR 87465(d)(2) (d) and 87465(e), Incidental Medical and Dental Care Services:

POC: Staff needs to be re-trained for medication dispensing and log.

POC date 8.23.2024: POC cleared during LPA visit.

-CCR 87506(b)(13), 87506(b)(15), 87506(b)(17)(A), 87506(b)(17)(B), 87506(b)(17) (c ) &, 87506(b)(17)(D) Resident Records:

POC: Licensee needs to fill-in residents functional capability, appraisal, pre-admission, functional capability, mental condition, social factor

POC date 8.23.2024: POC Cleared during LPA visit.

-CCR 87456(a)(2), Evaluation of Suitability for Admission:

POC: Admission agreement needs to be done when taking in a new resident.

POC date 8.23.2024: POC Cleared during LPA visit.

Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNNYBRAE HOME
FACILITY NUMBER: 197609684
VISIT DATE: 08/23/2024
NARRATIVE
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- CCR 87457(c ), 87463(a), & 87457(c)(1) Pre-Admission Appraisal:

POC: Pre-admission appraisal is needed when taking in new resident.

POC date 8.23.2024: POC cleared during LPA visit.

- CCR 87463(a) Reappraisal:

POC: Re-appraisal are needed

POC date 8.23.2024: POC cleared during LPA visit.

-CCR 87467(a) Resident Participation in Decision making

- POC: Prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility.


- POC date 8.23.2024: POC cleared during LPA visit.

- HSC 1569.885 (c ), 1569.886(d), & 1569.885(a) Admission Agreements

-Admission agreement is needed when admitting a new resident.

-POC date 8.23.2024: POC cleared during LPA visit.

-CCR 87507(l) 87507(a)(1)(A), 87507(a)(1)(B), 87507(b) 87507 (c ), 87507(d),87507(g), 87507(g)(3)(A)1, & 87464 (c ) Admission Agreements

-Admission agreement is needed when admitting a new resident.

-POC date 8.23.2024: POC cleared during LPA visit.

Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SUNNYBRAE HOME
FACILITY NUMBER: 197609684
VISIT DATE: 08/23/2024
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- CCR 87464(d) Basic Services

- Pre-admission for basic services needs to be done when taking in a new resident.

-POC date 8.23.2024: POC cleared during LPA visit.

- CCR 87508(a)(3) Register of Residents

- LIC 601 needs to be filled-in.

- POC date 8.23.2024: POC cleared during LPA visit.

- CCR 87608(a) Postural Support

- Resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used.

- POC date 8.23.2024: POC cleared during LPA visit.

-CCR 87411(a)(11) Personnel Records/Staff Training

- S3 needs health screening and TB test.

-- POC date 8.23.2024: POC cleared during LPA visit.

Exit interview conducted and copy of this report was printed and given.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC809 (FAS) - (06/04)
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