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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600255
Report Date: 09/24/2023
Date Signed: 09/24/2023 02:47:05 PM


Document Has Been Signed on 09/24/2023 02:47 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:SUNRISE OF SAN MATEOFACILITY NUMBER:
415600255
ADMINISTRATOR:MINNIE LACSON-WEBERFACILITY TYPE:
740
ADDRESS:955 S EL CAMINO REALTELEPHONE:
(650) 558-8555
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:85CENSUS: 62DATE:
09/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Abbie ApolinarioTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 9/24/23 at 9:00AM. LPA met with Abbie Apolinario, Administrator, Leslie Guerrero, Reminiscence Coordinator, StelaMarie Pham, Resident Care Director, Joanne-Ruth Gutierrez, Assisted Living Coordinator, Robert Graves, Maintenance Coordinator and stated the purpose of todays visit. The facility is licensed for a capacity of 85 non-ambulatory residents. Hospice approved for 20. Maximum 27 residents in Memory Care Unit rooms 400-416. The Administrator Certificate was observed for Abbie Apolinario expires 10/18/2024. There are 6 residents receiving hospice care services. There are 0 bedridden residents at this time. Facility has a delayed egress system.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed and conversed with residents during this visit. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be between 71-74*F which is within the required range of 68-85*F. The hot water temperature was measured between 112.3-114.6*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, pull alarm system and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed 3 staff and 3 resident files and conducted interviews during this visit.

Upon a file review the following items were discussed to be submitted with any changes annually:
Any addendums to Infection Control Plan, Designation of Facility Responsibility (LIC308), Liability Insurance
Personnel Report (LIC500), Administrator Certificate-Updated, LIC400, LIC402, Control of Property,

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given
SUPERVISOR'S NAME: Victoria BrownTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2023
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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