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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601336
Report Date: 09/10/2021
Date Signed: 09/10/2021 11:34:05 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SUNRISE PRIVATE CAREFACILITY NUMBER:
015601336
ADMINISTRATOR:NAGY, ARPADFACILITY TYPE:
740
ADDRESS:3234 EAST AVENUETELEPHONE:
(925) 449-0426
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 5DATE:
09/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Telesha Clarke, AdministratorTIME COMPLETED:
11:45 AM
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On 9/10/2021 at 8:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with administrator, Telesha Clarke and explained the purpose of the visit.

Upon entry, LPA's temperature was checked and asked to fill out visitor's log with COVID-19 questions. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common areas, and outdoor area. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at sinks and bathrooms.

During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food supplies, and paper supplies are sufficient.

Facility was given Technical Assistance regarding infection control guidelines and documented on LIC9102.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
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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