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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005479
Report Date: 03/28/2022
Date Signed: 03/28/2022 02:53:34 PM

Document Has Been Signed on 03/28/2022 02:53 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ROSSMOOR SUNSHINE VILLA-OAK WAYFACILITY NUMBER:
306005479
ADMINISTRATOR:RESURRECCION, FLORMINEFACILITY TYPE:
740
ADDRESS:12772 OAK WAY DRIVETELEPHONE:
(562) 572-9931
CITY:ROSSMOORSTATE: CAZIP CODE:
90720
CAPACITY: 6CENSUS: 6DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Eloisa Reyes - Caregiver
Flormine Resurreccion - Assistant Administrator		TIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Rossmoor Sunshine Villa-Oak Way. The purpose of today's visit was to conduct a Required 1 Year inspection. LPA Velazquez was allowed entry into the facility and met with Caregiver Eloisa Reyes. Caregiver Maureen Viloria was also present. Assistant Administrator (AA) Flormine Resurreccion arrived shortly after LPA's arrival. The facility is licensed for 6 non-ambulatory residents of which 2 may be bedridden. The facility has a Hospice waiver for 5 residents. There are currently 6 residents living in the facility. The last emergency disaster drill was conducted on February 3, 2022. LPA Velazquez observed the Complaint poster was not the correct size pursuant to regulation and advised AA to obtain the Complaint poster in the correct size of 20" x 26" and to prominently display it in the entry area.


At 1:38 PM LPA Velazquez conducted a tour of the physical plant along with AA Resurreccion. The 1 story home consists of 6 resident bedrooms each with their own ensuite bathroom. The facility also has a living room, dining room, and kitchen. The 6 residents in the facility appeared well-groomed and well cared-for. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. LPA Velazquez observed bed rails and/or postural support bars in the resident bedrooms. AA Resurreccion indicated there were written physician orders for the bed rails and postural support bars present in the resident files. Resident bathrooms were checked. Resident bath towels and personal hygiene supplies were adequately stocked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. LPA Velazquez tested the hot water temperature in the resident bathrooms and the temperature measured at 113.9 degrees Fahrenheit in the first bathroom, at 105.8 degrees Fahrenheit in the second bathroom, at 111.9 degrees Fahrenheit in the third bathroom, at 109.5 degrees Fahrenheit in the fourth bathroom, at 108.7 degrees Fahrenheit in the fifth bathroom, and at 106.8 degrees Fahrenheit in the sixth bathroom which AA
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2022
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ROSSMOOR SUNSHINE VILLA-OAK WAY
FACILITY NUMBER: 306005479
VISIT DATE: 03/28/2022
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Resurreccion verified. LPA Velazquez inspected the kitchen along with AA Resurreccion. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged. The smoke and carbon monoxide detectors were tested and found to be operational. Medications, toxins and sharps were locked and inaccessible to residents. The auditory alarms throughout the facility were in operating condition. LPA Velazquez observed the presence of cameras in the common areas of the facility. First Aid kit was checked and found to be in order. The facility did have a First Aid manual dated 2014 and LPA Velazquez advised AA Resurreccion to obtain an updated First Aid manual.

LPA Velazquez along with AA Resurreccion toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards and LPA observed the 2 exit gates were not in operating condition which AA Resurreccion verified. AA Resurreccion provided LPA Velazquez with documentation indicating the gates are currently being serviced. There were no security bars or weapons on the premises.

No resident or staff files were reviewed at the time of this visit. LPA Velazquez informed AA Resurreccion to ensure a written physician's order indicating the need for the bed rails and postural support bars is present in a resident's file pursuant to Title 22 Regulation Section 87608 Postural Supports which LPA reviewed with AA Resurreccion.




There were no deficiencies issued during this Required 1 Year inspection. An exit interview was conducted with Assistant Administrator Flormine Resurreccion and a copy of this report was provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC809 (FAS) - (06/04)
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