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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600255
Report Date: 12/23/2020
Date Signed: 12/23/2020 04:11:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SUNRISE OF SAN MATEOFACILITY NUMBER:
415600255
ADMINISTRATOR:STEPHANIE HALLFACILITY TYPE:
740
ADDRESS:955 S EL CAMINO REALTELEPHONE:
(650) 558-8555
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:85CENSUS: 55DATE:
12/23/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Stephanie HallTIME COMPLETED:
04:10 PM
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On December 23, 2020, Licensing Program Analyst (LPA) Shabana Buksh conducted an unannounced case management inspection. This inspection was conducted to obtain information for an unusual incident that occurred on 12/20/2020. LPA interviewed, Executive Director. LPA requested R1's hospice care plan, admission agreement, corresponding emails, names of Kaiser and facility staff to be interviewed. Executive Director would be providing all pertinent documents related to this incident by 12/28/2020. LPA would be following up with Executive Director and also interviewing the Wellness nurse on 12/28/2020.

This incident Needs Further Investigation.

LPA sent the report to Administrator for review and signature.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Shabana BukshTELEPHONE: (650) 266-8810
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020
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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