<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850392
Report Date: 10/28/2024
Date Signed: 10/28/2024 11:59:14 AM

Document Has Been Signed on 10/28/2024 11:59 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SUNNYSIDE MEMORY CARE, INC.FACILITY NUMBER:
565850392
ADMINISTRATOR/
DIRECTOR:		ANDERSON, DANAFACILITY TYPE:
740
ADDRESS:89 MISSION DRIVETELEPHONE:
(805) 383-9539
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 12CENSUS: 0DATE:
10/28/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Allen BestTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Valeria Conway conducted an announced pre-licensing visit to the above
noted facility. The LPA met with Administrator, Dana Anderson and Licensee Allen Best. This is a new facility. An application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 07/21/2023. A Fire Clearance was approved for a maximum capacity of six (6) non-ambulatory residents and six (6) bedridden residents on 12/08/2023. A dementia program was included in the plan of operation. A Hospice Waiver has been requested. There are no staff rooms – ‘awake night staff only’.

The proposed physical plant is a one (1) story single family dwelling located in a residential neighborhood of
Camarillo, CA.

At 9:40 A.M., A tour of the physical plant was conducted and the following observed:

The facility named above is currently not in compliance. LPA reviewed with the Licensee and Administrator the required modifications that shall be completed prior to pre-licensing approval.

Once the Licensee has completed all discussed projects, the LPA will schedule a follow-up visit to verify compliance.

Exit interview.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1