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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850392
Report Date: 03/20/2025
Date Signed: 03/20/2025 12:43:40 PM

Document Has Been Signed on 03/20/2025 12:43 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
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:
03/20/2025
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Allen BestTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted an announced Pre-Licensing Inspection to the above listed facility. Fire inspector, Richard Martinez was present to confirm the ambulatory status of all rooms within the building. Upon arrival LPAs and Fire Inspector met with Licensee, Allen Best and Administrator, Dana Anderson. Entrance interview conducted.

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 on 12/08/2023, however further clarification is needed regarding capacity designation. Fire clearance is approved for a maximum capacity of twelve (12), six (6) bedridden and six (6) non-ambulatory residents. Licensee plans to submit a hospice care waiver to CCL.

The proposed physical plant is a one (1) story single family dwelling located in a residential neighborhood of Camarillo, CA. This facility will be housing residents with dementia. There are no client residing in the facility at the moment. This facility doesn’t have a staff room, facility will provide 24/7 care.

Fire extinguisher is fully charged and recently purchased. Administrator will submit proof of purchase to LPA. Fire alarms/carbon monoxide detectors were tested individually between 9:50 A.M. and 10:20 A.M. and were functional at the time of the visit. Fire Inspector requested licensee to install a battery-operated smoke detector in the hallway leading to the laundry room. LPAs observed all required postings on the facility wall. Licensee shall revise their Emergency Disaster Plan and Infection Control plan once operation begins.

Continued on LIC 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
VISIT DATE: 03/20/2025
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Continued from LIC 809

At 9:45 A.M. a tour of the physical plant was conducted and the following observed:

BEDROOMS: The facility consists of seven (7) bedrooms, which Room #3, #4, #5 and #7 is for double occupancy. All bedrooms were equipped and supplied with appropriate furniture including but not limited to a bed, a chair, a night stand, a lamp and a chest of drawers, bedding, and linens. LPAs observed a door dividing room #4 into two separate rooms. LPAs explained that door shall be removed and requested that an updated floor plan be submitted to CCL prior to licensure. No client bedroom will be used as a public or general passageway to another room, bath, or toilet. There were no visible hazards or discrepancies observed.

BATHROOMS: LPAs observed toilets and handwashing stations to be in operation condition. Solid waste containers are in good repair and have tight-fitting covers, hand bars and slip resistant mats. Water temperatures were measured in all residents’ bathrooms and measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit at the time of the visit.



KITCHEN: Appliances and fixtures appeared clean and functional. At the time of the visit, LPAs observed a sufficient amount of dining and cookware. Perishable food will be supplied once license is approved. Administrator is aware that food supply shall accommodate a maximum capacity of twelve (12) residents and facility staff for seven (7) days. Sharps and knives will be stored in locked kitchen cabinet. Medication will be stored in a locked cabinet. Facility will properly document medication on the Centrally Store Medication and Destruction log. There were no visible immediate hazards observed. Water temperatures measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit at the time of the visit.

Continued on LIC 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
VISIT DATE: 03/20/2025
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Continued from LIC 809-C

COMMON AREAS: These include the Family Room, Living Room and Dining Room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Facility has enough space to store clean common linen items such as bed sheets, towels, pillowcases, and mattress pads. LPAs observed night lights in all hallways and passages. Facility has an auditory signal system in place at the time of the visit. Facility is equipped with a fire door to enhance safety and prevent the spread of fire and were working properly at the time of the visit. Posters were observed all throughout the facility including personal rights notice, and information about how to report a compliant to CCL. LPAs did not observe the ombudsman poster. Licensee will contact the Long-Term Care Ombudsman agency to obtain one. Administrator will use extra cabinets to store facility’s first aid kit, emergency food and water supplies, non-perishable food, and hygiene products. LPAs observed a working phone available for residents use whenever needed.

OFFICE ROOM/LAUNDRY ROOM: LPAs observed a computer, printer an office desk. Here is where staff and residents’ files will be kept. Additionally, LPAs observed a washer and a dryer machine, a locked cabinet where cleaning supplies and detergents will be stored.

SURROUNDING GROUNDS: Garden and yard are easily accessible to residents, and they are sufficient in size, comfortable and appropriately equipped for outdoor use. There was a shaded area with proper furniture for outdoor use. LPAs observed two side gates. Sufficient space to accommodate outdoor activities for residents. There were no bodies of water on the premises. At the time of the visit, LPAs did not observe hand railings alongside the entire ramps, Licensee stated that handrails will be installed in about 2 weeks. This project shall be completed before licensure. Additionally, LPAs observed a planter blocking emergency exit in front of Room #5, licensee will remove planter and keep exit free of obstruction.



GARAGE: Facility does not have a garage.

LPAs inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service.



Continued on LIC 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
VISIT DATE: 03/20/2025
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Continued from LIC 809-C

COMPONENT III ORIENTATION: A Component III Orientation was conducted with the Administrator during today's visit.

The following needs to be completed/Photos sent to LPA prior to licensure:

 Picture showing door in room #4 has been removed
 Picture of planter blocking emergency exit has been removed
 Smoke detector test in the hallway leading to the laundry room
 Installation of handrails along the entire ramps
 Ombudsman poster
 Provide an updated facility sketch (LIC 999)
 Fire extinguisher’s purchase receipt.


This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. A copy of the Licensing Report was issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4