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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320035
Report Date: 11/04/2021
Date Signed: 11/04/2021 03:57:44 PM

Document Has Been Signed on 11/04/2021 03:57 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 DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:PACIFIC SUNRISE HOME IFACILITY NUMBER:
198320035
ADMINISTRATOR:CANTORIA, MARIAFACILITY TYPE:
740
ADDRESS:28134 LOMO DRTELEPHONE:
(310) 500-7223
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 6DATE:
11/04/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator Rachael TuazonTIME COMPLETED:
02:15 PM
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On 11/04/2021 around 1:00pm Licensing Program Analyst (LPA) Jose Calderon initiated an unannounced Case Management visit - Other to provide Technical Assistance to the above said facility. Today’s visit was conducted face to face with administrator Rachael Tuazon.

LPA Calderon tour consisted of a single-story home, all common areas which included but were not limited to; building entrances, reception areas, office, hallways, restrooms, dining room, kitchen, pantry, medication storage and patio area. LPA Calderon also reviewed the facility's entry procedures, body temperature monitoring practices, social distancing practices, protective facial covering practices and disinfection/sanitation practices with Administrator Rachael Tuazon.

The LPA Calderon also requested copies of the facility's records which includes but are not limited to Pre-Placement Appraisal’s, Admission Agreements, Identification and Emergency Information's, Reappraisals, Individual Needs and Services Plans, IPP assessments, Behavior assessments, Physicians Reports, Medication Logs, Incident Reports, Progress Notes, Hospital discharge notes for resident 1 who was transferred from facility Adorable Red beam Home on 10/30/2021 to Pacific Sunrise Home 1. On 11/04/2021 LPA Calderon interviewed Administrator Rachael Tuazon who states that she was advised that a staff member with the other facility had abused R1 and this was the reason R1 was moved to her facility. Administrator Tuazon states that she did not see any signs of abuse for R1 when she moved in and she and her staff inspected R1 for signs of abuse and could not find any.

A telephonic exit interview was conducted with administrator Rachael Tuazonl and a hard copy was provided by hand for signature.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2021
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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