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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320035
Report Date: 10/12/2024
Date Signed: 10/12/2024 11:27:48 AM

Document Has Been Signed on 10/12/2024 11:27 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:PACIFIC SUNRISE HOME IFACILITY NUMBER:
198320035
ADMINISTRATOR/
DIRECTOR:		CANTORIA, SAMANTHAFACILITY TYPE:
740
ADDRESS:28134 LOMO DRTELEPHONE:
(310) 500-7223
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY: 6CENSUS: 6DATE:
10/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:04 AM
MET WITH:Administrator Designee Rachel TuazonTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 10/12/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Administrator Designee Rachel Tuazon. The facility is licensed to serve six (6) non-ambulatory residents, all of which one (1) may be bedridden. The facility has a hospice waiver approved for six (6) residents. 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. The facility is clean, sanitary, and in good repair. Protective devices are in place, including non-slip mats and grab bars in all showers.

The Assistant Administrator Designee accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Resident bedrooms had the required furniture, bed linens, and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew, and a non-skid mat was in place. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Doorways were free of obstructions.

Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2024
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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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: 10/12/2024
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LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher, last serviced September 20, 2024 was observed in the kitchen area. Assistant Administrator Designee tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional.

Five staff records were reviewed, five out of five staff records had current first aid certificates and required criminal record clearances or criminal record exemptions.

Five resident records were reviewed and, five out of five resident records had medical assessments and pre-appraisal or reappraisals. Two residents’ medication was reviewed.

No deficiencies are being cited.

An exit interview was conducted, technical assistance provided, and a copy of this report was discussed and left with Administrator Designee Rachel Tuazon.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2024
LIC809 (FAS) - (06/04)
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