430708612-3-17-2024-26-AS-MPAA-D3G4XS-20240317193001

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430708612
Report Date: 03/15/2024
Date Signed: 03/17/2024 07:31:01 PM

Document Has Been Signed on 03/17/2024 07:31 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	SUNNYSIDE GARDENS		FACILITY NUMBER:	430708612
ADMINISTRATOR:	KAREN MANDAIR		FACILITY TYPE:	740
ADDRESS:	1025 CARSON DRIVE		TELEPHONE:	(408) 730-4070
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94086
CAPACITY:	84	CENSUS:	DATE:	03/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:36 PM
MET WITH:	Brisa Romero		TIME COMPLETED:	05:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced required annual inspection and met with facility's Business Office Director/Assistant Exec Director (BOD/AED) Brisa Romero The facility's census is 34 resident and 54 staff. LPA toured the facility, including entryway, common room, dining room, kitchen, laundry room, 4 bedrooms, 3 bathrooms, medicine room, and activity room. LPA toured the exterior of the facility and observed all walkways and emergency exits are free from obstruction. No prohibited items were observed in the resident rooms. All emergency exits are clear from obstruction. The facility has housekeeping schedule for the residents. LPA toured the memory care section and tested the door alarms and found it to be in good working condition. Facility has activities scheduled posted for the whole month. LPA observed residents participating during activity time. LPA tested the facility water temperature. Water temperature measured between 119 to 120 degree Fahrenheit. LPA observed sufficient supply of food, 2 days of perishable food and 7 days for non-perishable food. Fire extinguisher was last inspected on 9/21/2023. All toxins are kept in a locked room. Knives are locked and is not accessible to residents. LPA reviewed the facility's fire alarm log. The fire alarms system for the entire building was inspected and tested on 01/09/2024 and were found to be in good working condition (test result passed). continued to LIC 809C page 1 of 2

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNNYSIDE GARDENS	FACILITY NUMBER: 430708612
	VISIT DATE: 03/15/2024

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LPA reviewed 3 resident files and 3 staff files. LPA reviewed the Centrally Stored Medication and Destruction Report for 3 residents and found all records to be updated. Disaster training for the facility was updated. LPA reviewed the staff personnel record and training information and found record to be updated and complete.

No deficiency was cited during today's visit per CCR Title 22. This report was reviewed with Business Office Director/Assistant Exec Director (BOD/AED) Brisa Romero and a copy of the signed report was provided electronically by email due to printer error.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024

LIC809 (FAS) - (06/04)

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