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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708734
Report Date: 10/05/2021
Date Signed: 10/06/2021 08:23:42 AM

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:SUNRISE MANOR RESIDENTIAL CARE HOMEFACILITY NUMBER:
430708734
ADMINISTRATOR:AIDA MIRANDAFACILITY TYPE:
740
ADDRESS:790 & 792 LOS PADRES BLVD.TELEPHONE:
(408) 615-0999
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:6CENSUS: 6DATE:
10/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Gina SobrevillaTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Infection Control site visit today. LPA met with staff Gina Sobrevilla and called Administrator Aida Miranda to discuss the purpose of the visit.

LPA toured the facility inside and out with staff. Facility was observed to have a designated entry point for universal symptom screening. Hand sanitizers were available.

All bathrooms were inspected and observed supplied with hygiene products and paper towels. Bedrooms, kitchen, dining room, living room, and the outside grounds of the facility were inspected. All fire exit routes were clear of obstruction. Facility also observed to have adequate supply of Personal Protective Equipment (PPEs).

LPA reviewed the facility COVID-19 related infection control policies and procedures with staff including screening, surveillance testing, disinfecting, staffing, training, isolation, PPE use and inventory. Per staff, all facility staff and residents are 100% vaccinated.

Technical assistance was issued during today's visit. LPA reviewed report with, and a copy provided to Gina Sobrevilla.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne RoadillaTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
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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