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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200484
Report Date: 04/07/2023
Date Signed: 04/07/2023 04:39:52 PM

Document Has Been Signed on 04/07/2023 04:39 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SUNOL CREEK MEMORY CAREFACILITY NUMBER:
019200484
ADMINISTRATOR:ROSE, JESSICAFACILITY TYPE:
740
ADDRESS:5980 SUNOL BLVDTELEPHONE:
(925) 846-8283
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY: 46CENSUS: 34DATE:
04/07/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Jacqueline Scott, Business Office ManagerTIME COMPLETED:
02:30 PM
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On 4/7/2023 at 11:10AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct Case Management - Annual Continuation. LPA met with Business Office Manager, Jacqueline Scott.


During visit, LPA interviewed 3 staff starting at 11:43AM. At around 12:30PM, LPA reviewed staff training records and observed staff completed training which includes dementia, emergency, resident rights, hospice, ADL (Activities of Daily Living) care, and other topics.

At 2PM, LPA reviewed two residents' medications with their centrally stored records and MAR (Medication Administration Records). LPA observed medications were written on the centrally stored records and MAR showed medications were administered as prescribed by physician.

No deficiencies are being cited on this date.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2023
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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