079200753-8-5-2020-15-AS-KHOS-BSEJPN-20200812071350

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200753
Report Date: 08/05/2020
Date Signed: 08/05/2020 12:10:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/22/2020 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20200722164857

FACILITY NAME:	SUNRISE VILLA SAN RAMON		FACILITY NUMBER:	079200753
ADMINISTRATOR:	MAY, JERALYN		FACILITY TYPE:	740
ADDRESS:	9199 FIRECREST LN		TELEPHONE:	(703) 273-7500
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	140	CENSUS: 65	DATE:	08/05/2020
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Joseph Villanueva, Executive Director		TIME COMPLETED:	11:42 AM

ALLEGATION(S):

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Resident is being illegally evicted from facility

INVESTIGATION FINDINGS:

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On 08/05/20 at 10:00 AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a subsequent Facetime tele-visit with Executive Director (ED) Joseph Villanueva regarding the above allegation. Due to COVID 19 shelter in place order issued by the Governor on March 17, 2020, ED was not physically available to sign this report.

LPA reviewed R1's signed admission agreement dated 10/31/19 which stated that the facility has a non-smoking policy that is strictly enforced. Residents, staff and guests who wish to smoke must use the designated outside areas of the facility. Based on LPA's record reviews and interviews. R1 failed to comply with facility's general non-smoking policy despite several warnings and reminders from staff not to smoke inside his apartment dating back to 12/25/19 until 07/09/20.
Continued on next page, LIC 9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Rajind Basi	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20200722164857

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 VILLA SAN RAMON	FACILITY NUMBER: 079200753
	VISIT DATE: 08/05/2020

NARRATIVE

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Facility issued a 30 day eviction letter dated 07/21/20 to R1 due to his failure to comply with the general policy of non-smoking inside the facility with a residency termination date of 08/20/20. ED informed LPA that he has actively assisted R1 in getting ready with safely relocating to another facility.

Based on LPA' s interviews with staff & residents, observations and record reviews, this department has investigated the allegation that resident is being illegally evicted from facility. We have found that this complaint is unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

No deficiencies cited during this tele-visit investigation.

Due to COVID19 shelter in place order, ED was not physically available to sign this report.

Exit Interview conducted and a copy of this report emailed to ED.

SUPERVISOR'S NAME: Rajind Basi	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2020

LIC9099 (FAS) - (06/04)

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