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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005213
Report Date: 08/16/2024
Date Signed: 08/16/2024 03:26:00 PM

Document Has Been Signed on 08/16/2024 03:26 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
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:
08/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:31 PM
MET WITH:Flormine ResurreccionTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On August 16, 2024, at 1:31pm, Licensing Program Analysts (LPA) Edward Kim and Jenifer Tirre conducted a Case Management Deficiencies while on a complaint visit for Case #22-AS-20240812095815. LPAs Kim and Tirre were granted entry and met with Licensee (LI) Flormine Resurreccion and explained the purpose of the visit.

During an inspection visit, LPAs Kim and Tirre observed the following: the facility did not maintain personnel records of verification of required staff training and orientation for six (6) out of the twelve (12) records reviewed.

Based on the observations made during today's visit, a deficiency is being cited as per the Title 22 Division 6 Chapter 8 of the California Code of Regulations.

An exit interview was conducted and a copy of this report and the appeal rights were provided to Licensee Flormine Resurreccion
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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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Document Has Been Signed on 08/16/2024 03:26 PM - It Cannot Be Edited


Created By: Edward Kim On 08/16/2024 at 03:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROSSMOOR SUNSHINE VILLA-RUTH ELAINE
FACILITY NUMBER: 306005213

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2024
Section Cited
CCR
87412(c)

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87412 Personnel Records (c) Licensees shall maintain in the personnel records verification of required staff training and orientation.
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Licensee states they will make records into compliance by giving additional trainings and send proof to CCLD via email to edward.kim@dss.ca.gov by POC due date August 26, 2024
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Based on observation, interview, and record review, LPAs Kim and Tirre observed the facility did not maintain personnel record verification of staff training in six out of twelve staff files. This poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024


LIC809 (FAS) - (06/04)
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