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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320035
Report Date: 10/12/2023
Date Signed: 10/12/2023 03:45:10 PM

Document Has Been Signed on 10/12/2023 03:45 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:PACIFIC SUNRISE HOME IFACILITY NUMBER:
198320035
ADMINISTRATOR:CANTORIA, SAMANTHAFACILITY TYPE:
740
ADDRESS:28134 LOMO DRTELEPHONE:
(310) 500-7223
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 4DATE:
10/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:46 AM
MET WITH:Raquel Tuazon, AdministratorTIME COMPLETED:
03:44 PM
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Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced Annual required visit and an infection control inspection to the above facility. LPA was met by Raquel Tuazon, Administrator the purpose of today’s visit was explained.

There are currently (4) residents in the facility, (3) are non-ambulatory (1) bed bound. The facility is a single-story structure located in a residential neighborhood. It has a ramp that goes along the west side of the facility. It consists of (5) bedrooms, (3) full bathrooms, shaded back yard, front yard, laundry room and attached garage.

LPA and Administrator toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. INFECTIOUS CONTROL PRACTICES - LPA observed a sanitizing station at the facility entry & visitors and temperatures are logged and checked sanitizer/soap and paper towels in all the bathrooms and additional sanitation supplies are stored in hall closet and garage. LPA observed staff wearing masks, Residents private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder, Fit testing completed for staff, infectious Control Plan posted and/or in folder, Emergency infectious Plan posted, required postings throughout the facility. Visitor designated area, resident temperatures are checked and logged (as needed). Emergency contacts updated and posted; PPEs are enough for 30 days. All resident's and staff are vaccinated and boosted. OPERATIONAL REQUIREMENT - Fire clearances are incompliance. PHYSICAL PLANT ENVIRONMENTAL SAFETY - Bedrooms are occupied by residents and contain the mandated furniture. One staff bedroom. Bathrooms have nonskid mats, bars, and are clean and operational. (1) fire extinguisher is fully charged. First Aid kit complete with manual. The water temperature is at 117 degrees Fahrenheit. Linens and personal hygiene supplies are adequate.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2023
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: PACIFIC SUNRISE HOME I
FACILITY NUMBER: 198320035
VISIT DATE: 10/12/2023
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A comfortable temperature is maintained in the facility. Smoke detectors and carbon monoxide detectors are complying and operational. hazardous toxins and/or items are inaccessible to residents. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. Exit, walkways and/or passageways, front yard and back yard are free of debris and/or hazards. The facility is in good repair. STAFFING AND PERSONNEL RECORD TRAINING - 3 staff files are current with valid CPR cards, egress system operational, no volunteers at the facility. RESIDENTS REC - INCIDENT REPORT- 4 Resident files are current along with medications. RESIDENT'S RIGHTS - Internet access along with computer, visitor policy posted, PUB 475 posted. PLANNED ACTIVITIES - shaded area, indoor and outdoor activity area. FOOD SERVICE - Ample supply of perishable and nonperishable food and menu posted. INCIDENTAL M&D – The MARS is updated and complete. Resident’s medications are being given as prescribed by their physician. DISASTER PREPAREDNESS – The facility has an emergency and disaster plan, staff knows were shut off valves are located, flashlights available along with batteries, cell phones, additional emergency provisions, and conducted fire drill in April 2023. RESIDENT'S W/SHN - Some residents within facility require postural support, residents using oxygen have signs posted on doors.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time



An exit interview was conducted with Raquel Tuazon Administrator, a hard copy of report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jeremiah Randle
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC809 (FAS) - (06/04)
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