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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602951
Report Date: 03/06/2025
Date Signed: 03/06/2025 01:29:04 PM

Document Has Been Signed on 03/06/2025 01:29 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PACIFIC SUNSET - EUREKA SPRINGSFACILITY NUMBER:
374602951
ADMINISTRATOR/
DIRECTOR:		MUNAR, VICTORINOFACILITY TYPE:
740
ADDRESS:3131 CRANE AVENUETELEPHONE:
(760) 294-6997
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 6CENSUS: 3DATE:
03/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:Amelia Perlow, CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On 03/06/25 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit. LPA was greeted and granted entry by Caregiver Amelia Perlow, where explained the purpose of the visit. The administrator Carlo Munar was unable to come to the facility due to being out of town. The facility has an approved hospice waiver for (3), with (2) residents currently receiving services.
LPA conducted a tour of the interior and exterior areas of the facility. The facility was observed to be clean, clutter and odor free. The medications, sharps, and chemicals were observed to be locked and inaccessible to residents in care. The smoke and carbon monoxide detectors were tested and observed to be operable. The emergency disaster drills are being conducted on a quarterly basis, the last drill was conducted on 12/11/24, with a drill being due this month (March 2025). There are no pools, bodies of water or known guns and ammunition on the premises. The facility is a single story structure consisting of (5) bedrooms and (3.5) bathrooms. There is one room designated for a live in caregiver. The food supply was observed to be sufficient. The water temperature was tested and measured to be 105 degrees Fahrenheit in the (2) resident bathrooms.
All staff present were observed to have obtained criminal record clearance and were associated tot he facility with valid CPR certification. The administrator on record needs to be changed and was observed to have submitted their renewal application. The facility annual fees are due on or before 03/17/25, LPA provided PIN 746115, should the Licensee wish to pay electronically. The governing body was observed to be active and in good standing. The facility is to submit the following: updated LIC610E, Emergency Disaster Plan as well as an updated Centrally Stored Medication And Destruction Record for all (3) residents in care to the department no later than 5pm on 03/02/25. During the employee file review LPA observed for the (3) staff files to not contain proof of ongoing/current training(s) received. Deficiency cited. Based on today's inspection A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8). An exit interview was conducted and a copy of this report, 809D, appeal rights, LIC9098-Proof of Corrections form and LIC811-Confidential names list was reviewed and provided to Amelia Perlow.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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 03/06/2025 01:29 PM - It Cannot Be Edited


Created By: Javina George On 03/06/2025 at 01:04 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFIC SUNSET - EUREKA SPRINGS
FACILITY NUMBER: 374602951

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

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 3 out of 3 times as the on going training records were not in the employee personnel files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2025
Plan of Correction
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The Licensee agrees to update the employee files and insert the documentation of ongoing staff training. POC is to be submitted to the department by 5pm on the due date indicated.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


LIC809 (FAS) - (06/04)
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