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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600255
Report Date: 06/24/2024
Date Signed: 06/24/2024 04:37:44 PM


Document Has Been Signed on 06/24/2024 04:37 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:ABBIE APOLINARIOFACILITY TYPE:
740
ADDRESS:955 S EL CAMINO REALTELEPHONE:
(650) 558-8555
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:85CENSUS: 68DATE:
06/24/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:22 PM
MET WITH:Joanne Gutierrez, Assisted Living Coordinator and Trish Redito, Business Office CoordinatorTIME COMPLETED:
04:45 PM
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On June 24, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 3:22 PM to conduct a Case Management visit regarding a resident, R1 who fell. LPA Calandra was greeted by Trish Redito, Business Office Coordinator and explained the purpose of the visit. Joanne Gutierrez, Assisted Living Coordinator joined later during the visit.

LPA Calandra spoke to Trish Redito and Joanne Gutierrez regarding the incident to gather additional information about the situation. LPA Calandra also interviewed S1 who responded to R1's pendant request
for help.

LPA Calandra received the following document(s):

-Call button response time for R1

No deficiencies were cited during today's visit. This report was reviewed with Trish Redito, Business Office Coordinator and a copy of the report left at the facility.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2024
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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