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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708612
Report Date: 03/30/2022
Date Signed: 03/30/2022 12:30:45 PM


Document Has Been Signed on 03/30/2022 12:30 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: 43DATE:
03/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Simi RaiTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the annual inspection to focus on infection control and met with Assistant Executive Director, Simi Rai. Upon arrival, it was brought to the LPAs attention that five minutes prior to arrival a resident tested positive for COVID-19.

During visit, facility was undergoing mass testing in which LPAs tour was limited to parts of the facility due to exposure. LPA toured the common areas to include the central entry point, assisted living dining room, activity rooms, and common bathrooms.

The central entry point was observed to have a required mask sign and screening area for all residents, visitors, and staff. Hand sanitizer available upon entry. All staff observed to be wearing a mask. Common bathrooms were observed with hand washing signs, hygiene products, and paper supplies. The facility has infection control posters posted throughout to include hand washing, stop the spread of germs, and cover your cough. Facility disinfect and sanitize high touch surfaces daily and as needed. Facility has a proper plan and procedure for visitation. LPA observed facility to have enough PPE supplies. All staff are N95 fit tested.

LPA reviewed the facility's isolation procedures to include a designated staff per shift to be caring for persons with COVID, designated entrance and exit areas for residents, visitors, and staff, PPE cart located outside the residents room, staff training on donning and doffing PPE, increased monitoring, and proper signs posted inside and outside isolation room.

No deficiencies cited during today's visit per California Code of Regulations, Title 22.

This report was reviewed with Simi Rai and a copy of this report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
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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