430708734-9-8-2022-26-AS-KHOS-CKHJ9P-20221024065124

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430708734
Report Date: 09/08/2022
Date Signed: 09/08/2022 12:33:34 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/31/2022 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20220831091357

FACILITY NAME:	SUNRISE MANOR RESIDENTIAL CARE HOME		FACILITY NUMBER:	430708734
ADMINISTRATOR:	AIDA MIRANDA		FACILITY TYPE:	740
ADDRESS:	790 & 792 LOS PADRES BLVD.		TELEPHONE:	(408) 615-0999
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95050
CAPACITY:	6	CENSUS: 5	DATE:	09/08/2022
		UNANNOUNCED	TIME BEGAN:	09:44 AM
MET WITH:	Aida Miranda		TIME COMPLETED:	12:32 PM

ALLEGATION(S):

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Facility has pests

INVESTIGATION FINDINGS:

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Licensing Program Analyst Ryker Heberle (LPA) arrived at the facility in order to conduct an unannounced complaint investigation regarding the above allegation. LPA contacted Administrator Aida Miranda (Admin) via telephone. Admin was on her way to a doctor's appointment and was unable to attend the inspection. Admin gave facility caregiver Zenaide Bose (R1) permission to sign in her stead.

During telephone call, LPA indicated to Admin that the allegation regarded pests within the facility. Admin stated that while the facility had bed bugs, they had already sprayed and treated for them, and the facility was now pest free. LPA asked Admin whether or not they had reported the bedbug outbreak and treatment to licensing. Admin stated that she had forgotten to do so. Admin stated they would provide receipts of bed bug treatment to licensing.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

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 3

Control Number 26-AS-20220831091357

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SUNRISE MANOR RESIDENTIAL CARE HOME	FACILITY NUMBER: 430708734
	VISIT DATE: 09/08/2022

NARRATIVE

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During complaint pre-investigation, The Department interviewed 2 witnesses. Both stated that bed bugs had been personally witnessed at the facility. W1 presented photographic evidence of a bed bug outbreak at the facility

During tour of the facility, LPA did not observe any pests within the facility. LPA inspected 6 bedrooms, kitchen, living room, bathroom, and back yard. In interviews with facility residents, 2 out of 4 stated that the facility had previously had issues with pests, but that they were currently having no issues. 1 out of 4 residents interviewed stated that they had been bitten by bed bugs in their room, but that they have had no issues since the facility had been treated. In interviews with facility staff, 2 out of 2 staff members confirmed that the facility had bed bug treatments, and both had personally witnessed pests.

Based on record review and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. A deficiency is being cited. See LIC 9099-D.

An exit interview was conducted, and Plan of Correction was developed and reviewed with Administrator, Aida Miranda. Report was signed by caregiver Zenaide Bose A copy of this report and appeal rights were provided via email due to printer error.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20220831091357

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SUNRISE MANOR RESIDENTIAL CARE HOME	FACILITY NUMBER: 430708734
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/09/2022 Section Cited CCR 80087(a)(1)	1 2 3 4 5 6 7	80087(a)(1) -Buildings and Grounds- The facility shall be clean, safe, sanitary and in good repair at all times... (1) The licensee shall take measures to keep the facility free of flies and other insects. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Facility has already completed insect treatment. Licensee to adhere to follow up instructions provided by exterminators. Licensee to provide staff training on bed bug identification and to review reporting requirements.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not ensure that the facility remained free of bed bugs and did not report infestation to licensing. This presented a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	Written plan of correction to be submitted by POC due date.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC9099 (FAS) - (06/04)

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