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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609684
Report Date: 04/14/2025
Date Signed: 04/14/2025 02:15:51 PM

Document Has Been Signed on 04/14/2025 02:15 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
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: 5DATE:
04/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Jeffrey Savella - AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 4/14/25 an unannounced annual visit was conducted by Licensing Program Analyst (LPA) Perchui Milena Khurshudyan. Upon arrival, LPA met with the Caregiver Josephine Espiritu, who granted access to the facility. LPA introduced herself by showing her badge and explained the reason for the visit. Shortly after the Administrator, Jeffrey Savella arrived and helped with staff/residents’ files and medications.

During today's visit, LPA conducted a physical plant walk through, at approximately 9:45am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22.

The following was observed: The facility is a single-story home and is licensed for capacity of six (6) residents, of which six (6) may be Non-Ambulatory and of which fire clearance for one (1) Bedridden. Facility also has a hospice waiver for six (6) residents. There are six (6) bedrooms, of which five (5) bedrooms are designated for residents’ use and one (1) bedroom #1 is designated for staff use only. All bedrooms observed to be appropriately furnished and have appropriate lighting. There are four (4) bathrooms in the facility of which three (3) are designated for residents’ use and one (1) for staff use. LPA observed bathrooms have soap, paper towels and hand washing signs. The hot water temperature measured at 10:10am to be 109°F. Extra towels and linens were readily available in the linen closet located in the hallway next to the entrance door. There are grab bars for each toilet and shower, bathrooms have non-skid mats. All trash cans in bathrooms had fitted lids to protect from cross contamination. LPA observed facility alarms were present on all exit doors and all of the signals were functional.

SMOKE DETECTORS/CARBON MONOXIDE. The smoke detectors and carbon monoxide are hard wired, inter-connected and were located throughout the facility. At 10:55am they were tested and observed to be operational. The facility has two (2) fire extinguishers that were last purchased on 2/13/2025.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 04/14/2025
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KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, dish washer and sink. The kitchen appliances and fixtures were functional. LPA observed the kitchen area, there was sufficient stock of one week non-perishable foods and two days of perishable foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed that sharp objects were stored inside the kitchen cabinet, which was observed to be locked and inaccessible to residents in care. Extra emergency food was properly stored inside the pantry. The common areas which include dining and living room appeared clean and were properly furnished. Temperature was comfortable it was measured at 11:05am to be 74°F. No obstructions and or tripping hazards throughout the facility found.

MEDICATION: LPA observed medications are centrally stored and locked inside the kitchen cabinet. First Aid kit was also available and stored inside the kitchen cabinet, inaccessible to residents in care. It was checked by the LPA to be complete with the new manual available with it. Facility operated with two (2) shifts and has three (3) staff for AM shift and three (3) awake caregivers for PM shift.

COMMON AREAS: LPA observed living room and a dining room that appeared generally clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. Facility has land line; LPA checked its operational.

LAUNDRY ROOM: Laundry machines are located by the kitchen area and observed to be operational. LPA observed chemicals and detergents were stored and locked inside the cabinet located outside of the facility. LPA discussed the importance of keeping potentially dangerous items locked at all times.

SURROUNDING GROUNDS: LPA observed sufficient yard space with fenced backyard. Appropriate outdoor furniture, with covered shaded area available for residents to rest and enjoy outside weather. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. Exit doors were unlocked and free of obstructions. The facility does not have a swimming pool or body of water. There is no garage in the property.

FILE REVIEW: Between 11:15am to 12:30pm, LPA reviewed records and files of five (5) residents and four (4) staff/caregivers. A review of staff and resident records appeared to be complete. Resident’s files contain signed admission agreements and a medical assessment, and all other required documents/forms.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 04/14/2025
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A review of staff records indicates that all facility staff and who required caregiver background checks have received criminal record clearances. There are no residents with prohibited conditions residing at the facility.

Facility provides activities to the residents in care, two out of five residents participate in Adult Day program. An emergency exit plan/sketch along with other posting requirements are posted on the wall by the entrance area.

Medications Review: At approximately 12:35pm. LPA reviewed Centrally Stored Medication Destruction Records for proper documentation. Facility also maintains Medical Administration Records (MAR). PRN medications have written orders from a physician. Potentially dangerous items are kept inaccessible to residents in care.

LPA collected LIC500, LIC9020, copy of Liability Insurance Certificate.

No citation issued during today’s visit.

Exit interview conducted and copy of this report signed and delivered.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4