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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005651
Report Date: 12/11/2024
Date Signed: 12/11/2024 12:06:31 PM

Document Has Been Signed on 12/11/2024 12:06 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:SUNRISE GARDENFACILITY NUMBER:
306005651
ADMINISTRATOR/
DIRECTOR:		PARDEDE, FERDINANDFACILITY TYPE:
740
ADDRESS:29751 ANA MARIA LANETELEPHONE:
(949) 423-6175
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 5DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Caridad AlfonzoTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. The facility is licensed for a capacity of 6 non-ambulatory residents with a hospice waiver for 3. LPA observed the See Something, Say Something sign measured 17 by 11 inches. LPA observed all the required postings in the main entry way of the facility. Facility has 6 bedrooms, 5 bathrooms, living room, dining room, kitchen and a 2 car garage. LPA and staff toured the facility. LPA observed the fireplace in the dining room and the fireplace in the living room are screened. LPA observed all resident rooms are clean and organized. All resident rooms had the required furnishings. LPA observed all bathrooms are clean and operational. Hot water measured between 107.5 to 117.7 degrees Fahrenheit in all 5 bathrooms. LPA toured the kitchen. The kitchen is organized and clean. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. Knives are kept locked in a kitchen drawer. Cleaning supplies are kept locked under the kitchen sink. LPA observed the fire extinguisher in the kitchen is fully charged. Smoke detectors/carbon monoxide detectors tested operational. LPA toured the backyard. No bodies of water observed. There is a covered patio with shaded seating for residents to sit outside. Both exit gates are operational. No obstacles or hazards observed in the backyard. LPA reviewed staff files. LPA observed 3 out of 3 staff members have background clearances but not all staff are associated to the facility. Staff 1 is associated to the facility, but Staff 2 and Staff 3 are not associated to the facility. LPA observed Staff 2 and Staff 3 leave the facility. LPA observed Staff 1 did not have any current training except CPR training. LPA reviewed 5 resident records, no discrepancies observed. LPA reviewed 5 resident medications, no discrepancies observed. LPA observed and staff verified there is no internet device for dedicated resident use. LPA reviewed facility documents, there is no evidence of any emergency drills being conducted for the staff. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Civil penalty assessed on today's date. An exit interview was conducted with the facility representative and a copy of the report, along with appeal rights and civil penalty was provided to the facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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 12/11/2024 12:06 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 12/11/2024 at 11:24 AM
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: SUNRISE GARDEN
FACILITY NUMBER: 306005651

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 3 staff members which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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Licensee agrees to have all staff members background cleared and assoicated to the facility prior to any staff working at the facility. Licensee to assoicated Staff 2 and Staff 3 to the facility and to report to the LPA when completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 12/11/2024 12:06 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 12/11/2024 at 11:24 AM
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: SUNRISE GARDEN
FACILITY NUMBER: 306005651

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 staff members which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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Licensee agrees to train Staff 1 in accordance with HSC 1569.625 and to provide proof of training to the LPA by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/11/2024 12:06 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 12/11/2024 at 11:36 AM
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: SUNRISE GARDEN
FACILITY NUMBER: 306005651

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2024
Plan of Correction
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Licensee agrees to conduct a fire drill for all staff members and to submit documentation of the completed drill to the LPA. Licensee agrees to comply with HSC 1569.695 and to submit a statement of understanding to the LPA that they have read and understand HSC 1569.695.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
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