<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005213
Report Date: 07/06/2021
Date Signed: 07/13/2021 08:22:47 AM

Document Has Been Signed on 07/13/2021 08:22 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ROSSMOOR SUNSHINE VILLA-RUTH ELAINEFACILITY NUMBER:
306005213
ADMINISTRATOR:RESURRECCION, FLORMINEFACILITY TYPE:
740
ADDRESS:3212 RUTH ELAINE DRIVETELEPHONE:
(562) 572-9931
CITY:ROSSMOORSTATE: CAZIP CODE:
90720
CAPACITY: 6CENSUS: 6DATE:
07/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Licensee Flormine ResurreccionTIME COMPLETED:
02:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Shobhana Frank , made an unannounced visit to the facility to conduct one year required Inspection. LPA was greeted by Licensee Flormine Resurreccion granted entry and lead the tour of the facility indoors and outdoors.
The following was observed:

Two staff and 6 residents were present at the time of inspection. Facility has a capacity of six (6) residents, ages sixty (60) and above. The facility is operating in the capacity and conditions approved by CCL.
Facility is a single story 6- bedrooms; 6 bathrooms house with an attached garage. The facility is equipped with a living room, dining area, office and activity area, powder room. Bedrooms are single occupancy. Each bedroom has attached bath room. All bathrooms have a working toilet, wash basin, grab bar, rolling shower, accommodates non-ambulatory clients in a wheel chair.
LPA observed COVID - visitation station equipped with hand sanitizer, thermometer, visitors log. LPA observed COVID posters throughout the facility.
LPA observe the facility to be clean and in good repair. Physical Plant and Safety of Environment/Operational Requirements. Smoke detectors and carbon monoxide detectors which were operational auditory device in each bedrooms and bathrooms are operable, facility has water fire sprinklers throughout the facility. Fire extinguishers are charged, mounted and dated 3/20/21. All outdoor and indoor passageways are free of obstruction. Night lights and emergency lighting is present. A locked area is provided for medications and sharp objects.
There is a telephone working at this location. The LIC 610E, emergency disaster plan is maintained. LPA reviewed LIC 808 Mitigation Plan. The facility has a current written definitive plan of operation. The facility is maintained in conformity with the regulations adopted by the state fire marshal. There are no bodies of water located on premises. Emergency Phone Numbers, Exit Plan & Menu: Posted & readily available for review.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2021
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ROSSMOOR SUNSHINE VILLA-RUTH ELAINE
FACILITY NUMBER: 306005213
VISIT DATE: 07/06/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Back yard with covered patio and without hazards, outdoor and indoor passageways are free of obstruction. LPA observed board games, books, exercise periods, puzzles, art (coloring, sketching, etc.) and other recreational materials for the residents use locate by living room. Adequate supply of linens and hygiene supplies are stored in main hallway closet.
LPA observed meal being served. The meal is adequate to meet the nutritional needs of the residents. Food prep areas are clean and organized. Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. Sharps were observed to be kept in a locked closet.
Facility Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational.
The refrigerators and freezers were installed with the required thermostats.
Toxins: Locked/stored in cabinet by the laundry room.
Water Temperature tested and recorded at 115 degrees Fahrenheit.
Medications and First-Aid Kit stored in the kitchen pantry.

LPA reviewed two staff file two resident file, interviews were conducted.
Reviewed two resident file -Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medical and Dental- LPA facility is meeting documentation requirements. Resident Rights are posted in the facility and a copy is signed on file. Dementia and hospice regulation requirements are being met.
Reviewed two staff file - Personnel Records, Training and Staffing- CPR and annual training requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the residents in care. The facility administrator is present a sufficient number of hours to maintain the facility. Administrator certification is current.
Facility has provided copy of Certificate of Liability Insurance - expires in 6/2022.
Based on the information received during this visit today, there are no deficiencies being cited in the area inspected.
An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2