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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430708612
Report Date: 12/14/2024
Date Signed: 12/15/2024 06:12:42 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/23/2022 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220823145843
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: 41DATE:
12/14/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Brisa RomeroTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility is not addressing insect infestation

Staff do not give prescribed medication to resident
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 12/14/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the weekend manager on duty, Brisa Romero, who also held the role as the Assistant Executive Director at this time.
A brief interview was conducted with the facility representative Brisa Romero at this time.
Current census was 41 residents.
The purpose of this visit was to inform this facility, and its representative Brisa Romero, that an ongoing investigation has been completed and the following findings were being delivered at this time.
Based on a review of the facility medication administration record (MAR) and dispensing log that was conducted, it was observed that the medications were being dispensed and documented as prescribed by the responsible licensed medical professionals at this time.
Based on a review of the facility's contracted third party vendor for pest control, Ecolab Pest Elimination Divison, it was observed that this company made one to two visits a month out to this facility. It was observed that the contract outlined services for cockroaches, rodents, flies and ants.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 26-AS-20220823145843
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: SUNNYSIDE GARDENS
FACILITY NUMBER: 430708612
VISIT DATE: 12/14/2024
NARRATIVE
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Based on a review of the pest control reports dating back to 02/02/2022, it was observed that the findings for these inspections performed by Ecolab did not show that there were issues of pests for this facility at that time.
It was observed that there were suggestions for structural concerns to fill gaps and holes within the kitchen area but no pest activity was found during the dates of service.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegations finding of Unsubstantiated meant that although the allegations may have happened or were valid, there was not a preponderance of the evidence to prove that the alleged violations occurred.

There were no deficiencies observed or cited at this time.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/23/2022 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220823145843

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: 41DATE:
12/14/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Brisa RomeroTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff are not ensuring resident wound is free from ants
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 12/14/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the weekend manager on duty, Brisa Romero, who also held the role as the Assistant Executive Director at this time.
A brief interview was conducted with the facility representative Brisa Romero at this time.
Current census was 41 residents.
The purpose of this visit was to inform this facility, and its representative Brisa Romero, that an ongoing investigation has been completed and the following findings were being delivered at this time.
Based on interviews conducted, it was learned that there was a resident, R1, who resided in the Memory Care Unit of this facility.
It was learned that there was the presence of ants that were discovered in the room of R1 and that the ants were observed to be also on R1 as well.
It was learned that this incident was reported to the management team of this facility. The resident, R1, was then moved to another room with a different type of flooring so that facility staff could better identify the
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20220823145843
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: SUNNYSIDE GARDENS
FACILITY NUMBER: 430708612
VISIT DATE: 12/14/2024
NARRATIVE
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presence of any ants and other pests if they were to be present at that time.

As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was left with the facility designated representative at this time.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20220823145843
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: SUNNYSIDE GARDENS
FACILITY NUMBER: 430708612
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2024
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This facility was found to be deficient as evidenced by the presence of ants in a
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The facility designated representative stated that the contracted pest control company, Ecolab, will be notified to concentrate and focus on the prevention of ants at this time.
A statement of correction, along with proof of contracted pest control services rendered for ant control, will be completed and submitted
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resident room which prompted a move to another room for the resident which posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
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into CCL by the due date.

This facility has provided forms and documents for contracted services through Ecolab for the prevention of cockroaches, flies, rodents and ants at this time. No further plan of correction required at this time.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5