019200722-9-30-2022-15-AS-KNGN-CJRSKR-20220930135710

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200722
Report Date: 09/30/2022
Date Signed: 09/30/2022 01:58:45 PM

Document Has Been Signed on 09/30/2022 01:58 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:	SUNRISE OF PLEASANTON		FACILITY NUMBER:	019200722
ADMINISTRATOR:	TRACY BURKE		FACILITY TYPE:	740
ADDRESS:	5700 PLEASANT HILL RD		TELEPHONE:	(925) 416-0238
CITY:	PLEASANTON	STATE: CA	ZIP CODE:	94588
CAPACITY:	103	CENSUS: 80	DATE:	09/30/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:22 AM
MET WITH:	Tracy Burke, Excutive Director		TIME COMPLETED:	02:05 PM

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On 9/30/22 at 11:22 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct Infection Control Inspection. LPA met with Tracy Brucke and explained the purpose of the visit.

The facility’s fire clearance was approved for 103 residents of which 83 may be non-ambulatory, 20 may be bedridden and 20 may be under hospice care.

LPAs toured the facility including but not limited to the bathrooms, bedrooms, dining areas, activity rooms, kitchen, laundry area, and outdoor. Centrally stored medications were locked in medicine carts. The facility has a written emergency disaster plan. Smoke detectors were interconnected. Facility was equipped with sprinkler system which was last inspected on 4/30/22. Fire extinguishers were lasted inspected on 6/6/22. Weekly menu was available. Facility has two memory care units located on the first floor with the exit doors equipped with delayed egress. Last fire drill was conducted on 9/30/22.

One week supply of nonperishable and 2-day supply of perishable foods were available. Comfortable temperature was maintained inside the facility and measured at 74 degrees Fahrenheit (F). Hot water temperature was measured at 115.2 degrees F in 3 bathrooms. Freezer’s temperature was registered at -8 degree F while the refrigerator’s temperature was recorded at 34 degrees F. There were adequate lights in each room. Hallways and passages were free of obstruction. Grab bars for each toilet and shower were installed.

During record review, LPA reviewed a sample of 10 staff records and observed 10 of 10 have health screening with TB test on file.

Report continue on LIC 809C...

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SUNRISE OF PLEASANTON	FACILITY NUMBER: 019200722
	VISIT DATE: 09/30/2022

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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/07/22:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

LIC809 (FAS) - (06/04)

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