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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708612
Report Date: 02/16/2022
Date Signed: 02/16/2022 03:54:53 PM


Document Has Been Signed on 02/16/2022 03:54 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:SUNNYSIDE GARDENSFACILITY NUMBER:
430708612
ADMINISTRATOR:KAREN MANDAIRFACILITY TYPE:
740
ADDRESS:1025 CARSON DRIVETELEPHONE:
(408) 730-4070
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY:84CENSUS: 42DATE:
02/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Simi RaiTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Steve Chang, and Licensing Program Manager (LPM) Sarah Yip, conducted Technical Assistant through tele-inspection (Zoom), and met with Assistant Executive Director (AED) Simi Rai.

The purpose of this TA Tele visit was to review the facility COVID-19 infection mitigation plan and conducted inspection of the facility to ensure plan is being carried out and to provide support and guidance to staff in mitigating the spread of virus.

During tele-visit inspection, a tour of the facility was conducted which started at the main entrance to check COVID-19 signage and screening procedures. The facility has the COVID-19 posters at the main entrance including hand sanitizer, face masks, thermometer, glove, and a visitor log book at the screening station.

The facility common areas were inspected such as the front desk, public restrooms, activity room, refreshment room, dinning area, and Hallway were observed. Assistant Living unit and Memory Care Unit were inspected. Resident rooms and isolation room were observed. Laundry room and backyard were inspected. COVID-19 signage were observed at main entrance and in facility. Washing hands for 20 seconds posters were observed at restrooms. Some trash cans were observed without covers in facility.

AED stated all the residents and staff are fully vaccinated. AED stated all residents except 3 and all staff except 2 are done with booster.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: SUNNYSIDE GARDENS
FACILITY NUMBER: 430708612
VISIT DATE: 02/16/2022
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Based on today's inspection, the facility is being recommended the following:

1. Facility to frequently wipe and disinfect high touch areas.
2. Facility to have trash cans with foot pedal cover.
3. Facility to conduct staff training at least monthly or frequently such as donning and doffing PPE and COVID -19 updates.
4. Facility use of N95 mask by staff must have completed a N95 mask fitting test conducted by medical professional per CalOSHA.
5. Do the laundry for negative residents first, then do the laundry for the positive residents.
6. N95 Seal check reference:
https://www.cdc.gov/niosh/docs/2018-130/pdfs/2018-130.pdf
https://www.youtube.com/watch?v=oU4stQgCtV8
7. Facility to review PINs (Providers’ Information Notification) through CCLD website: www.ccld.ca.gov.
8. Facility to reference https://youtu.be/H4jQUBAlBrI - donning PPE.
9. facility to reference https://youtu.be/PQxOc13DxvQ - doffing PPE.
10. facility to reference https://youtu.be/KmyxsnuREGs - How does viruses spread from surfaces to people.
11. facility to reference https://youtu.be/pIAH2l9Eg6g - How does viruses make you sick.
12. Facility to reference https://youtu.be/TCa7Gg1NUD4 - Why does contact time matter for disinfection.

No deficiencies cited during today's Tele Visit. Exit interview conducted with AED.
A copy of this report emailed to AED for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
LIC809 (FAS) - (06/04)
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