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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200726
Report Date: 09/19/2024
Date Signed: 09/19/2024 12:07:47 PM


Document Has Been Signed on 09/19/2024 12:07 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:SUNRISE CARE HOME IIFACILITY NUMBER:
019200726
ADMINISTRATOR:TAYAG, NANCY RFACILITY TYPE:
740
ADDRESS:1435 VIA LUCASTELEPHONE:
(510) 398-8677
CITY:SAN LORENZOSTATE: CAZIP CODE:
94580
CAPACITY:6CENSUS: 6DATE:
09/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Nancy Tayag, AdministratorTIME COMPLETED:
12:30 PM
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On 9/19/2024 at 10:30 AM, Licensing Program Analysts (LPAs) Jill Clancy-Czuleger and Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Administrator, Nancy Tayag and explained the purpose of the visit.

LPAs toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 113 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 09/19/2024. Emergency Disaster Plan was last posted on 05/10/2017. First aid kit was observed to be complete.

LPAs reviewed 6 residents records and 4 staff records; all were complete. LPAs also reviewed a sample of resident’s medications.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Ardalan GharachorlooTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
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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