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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004790
Report Date: 03/12/2025
Date Signed: 03/12/2025 11:46:05 AM

Document Has Been Signed on 03/12/2025 11:46 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ROSSMOOR SUNSHINE VILLA-KENSINGTONFACILITY NUMBER:
306004790
ADMINISTRATOR/
DIRECTOR:		RICARDO BANOSFACILITY TYPE:
740
ADDRESS:11802 KENSINGTON RD.TELEPHONE:
(562) 794-9047
CITY:ROSSMOORSTATE: CAZIP CODE:
90720
CAPACITY: 6CENSUS: 5DATE:
03/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Licensee Flormine ResurreccionTIME VISIT/
INSPECTION COMPLETED:
12:01 PM
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Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by Licensee Flormine Resurreccion after explaining the purpose for the visit. LPA observed that Administrator Ricardo Banos has a valid Administrator certificate which expires on January 11, 2026.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents, of which one may be bedridden, and has a hospice waiver for four. The facility is a one story home with five resident bedrooms, one of which is shared, five resident bathrooms, three of which are shared, a living room, a dining room, a kitchen, and an attached two car garage. LPA accompanied by the Licensee conducted a tour of the interior portion of the facility. On today's visit, LPA observed five residents in care, none of which are on hospice, and two care giving staff present. LPA observed residents relaxing in the living room. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected the five resident bedrooms, and they were observed to be free of any hazards. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. All resident beds had clean linens and blankets. LPA observed additional linens to be stored in a hallway storage cabinet. LPA inspected the five resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 113.3 and 117.8 degrees Fahrenheit.

LPA observed the kitchen has a two day perishable and seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. The six burner gas stove lights unassisted. LPA observed knives and sharps to be stored in a locked kitchen pantry. LPA observed chemicals and toxins to be stored in the locked kitchen pantry. Fire extinguishers are located in the kitchen and in the resident hallway. CONTINUED ON LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ROSSMOOR SUNSHINE VILLA-KENSINGTON
FACILITY NUMBER: 306004790
VISIT DATE: 03/12/2025
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Fire extinguishers were observed to be charged and serviced as of March 5, 2025. LPA tested the wired smoke detectors/carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on December 20, 2024. The centrally stored medication is kept in the locked kitchen pantry. LPA observed the First Aid kit to be stored in the locked kitchen pantry and it was observed to have all the required components. The door leading to the attached two car garage is kept locked and inaccessible to residents in care. The garage is used for storage and laundry. LPA observed chemicals and toxins to be stored in the locked two car garage. LPA observed the facility has a three day emergency food and water supply to be stored in the garage.

LPA and the Licensee conducted a tour of the exterior portion of the facility. LPA observed the exterior portion to be clear of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gates on the north side and southside of the facility are self-latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPA reviewed all five resident files. All the required documentation were present and current in the resident files reviewed. LPA reviewed all five residents’ medication and medication records. LPA reviewed three staff files. All staff are background cleared and associated to the facility.

Based on today's observations, no deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Licensee Flormine Resurreccion and Administrator Ricardo Banos and a copy of the report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC809 (FAS) - (06/04)
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