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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202358
Report Date: 01/05/2021
Date Signed: 02/03/2021 08:18:17 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SUNRISE ASSISTED LIVING OF MONTEREYFACILITY NUMBER:
275202358
ADMINISTRATOR:BILLY M. MITCHELLFACILITY TYPE:
740
ADDRESS:1110 CASS STTELEPHONE:
(831) 643-2400
CITY:MONTEREYSTATE: CAZIP CODE:
93940
CAPACITY:112CENSUS: 75DATE:
01/05/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Billy MitchellTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Technical Assist (TA) Visit via FaceTime platform with Billy Mitchell Executive Director/Administrator, Nadereh Nasseri Residential Care Director and Angela Pruitt RN, MSN, Health Facilities Evaluator Nurse (HFEN) California Department of Public Health. The purpose of the visit was to provide technical assistance for Infection Prevention and Control guidelines for Adult and Senior Care facilities.

LPA conducted a virtual tour of the facility. LPA and HFEN reviewed the facility policies and procedures to include screening, disinfecting, supplies, staffing, training, PPE usage and social distancing.

Informational Links and websites were provided to include Tying the Face Mask, PPE Eye Protection, UCSF Donning/Doffing PPE, Seal Check for N95 Mask and PPE Burn Calculator,

Report reviewed with Billy Mitchell and a copy emailed for signature purposes.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE:
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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