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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005213
Report Date: 08/15/2024
Date Signed: 08/15/2024 11:54:39 AM

Document Has Been Signed on 08/15/2024 11:54 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-RUTH ELAINEFACILITY NUMBER:
306005213
ADMINISTRATOR/
DIRECTOR:		ROBERT DALE KALAGAYANFACILITY TYPE:
740
ADDRESS:3212 RUTH ELAINE DRIVETELEPHONE:
(562) 572-9931
CITY:ROSSMOORSTATE: CAZIP CODE:
90720
CAPACITY: 6CENSUS: 5DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:28 AM
MET WITH:Maria Tavarez support staff TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA’s) Bernadette Allen made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Maria Tavarez who granted entry into the facility.

LPA observed 4 staff and 5 residents during the 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.

Physical Plant: LPA observed there are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms: they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately.

The hot water temperature tested within regulation at 104-124 degrees F. The facility is equipped with operating smoke detectors, carbon monoxide alarms and fully charge fire extinguishers. Posters such as personal rights, CCL complaint poster, and the disaster plan were posted in a common area.

All sharps are locked in a cabinet under the kitchen sink. There was a designated place for client/staff files locked in pantry. Overall, the facility appeared to be clean, in good repair, and operating in safe conditions.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed two (2) client files for admission agreements, updated physician reports, and Medication Administration Records (MAR’s) which appeared to be administered as prescribed by their physicians.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ROSSMOOR SUNSHINE VILLA-RUTH ELAINE
FACILITY NUMBER: 306005213
VISIT DATE: 08/15/2024
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LPA also reviewed two (2) staff files for First Aid/CPR certification, training's, and health screenings and appeared to be current.

Based on the observations made during today’s visit, no deficiencies were cited.

An exit interview was conducted, and this report was discussed and provided to Maria Tavarez support staff at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC809 (FAS) - (06/04)
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