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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708734
Report Date: 11/01/2022
Date Signed: 11/01/2022 04:09:03 PM


Document Has Been Signed on 11/01/2022 04:09 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: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: 3DATE:
11/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:08 PM
MET WITH:Gina SobrevillaTIME COMPLETED:
04:10 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 10/17/2022. LPA met with facility staff member Gina Sobrevilla (S1). Administrator Aida Miranda (Admin) was currently on an airplane and was unable to attend the inspection. S1 has authorization to sign on Admin's behalf.

LPA toured the facility, including living room, kitchen, dining room, laundry room/garage, 6 bedrooms, 2 bathrooms, and back yard. Admin confirmed that all staff and residents have been vaccinated.

No prohibited items noted in resident rooms. All rooms in facility noted to be adequately clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguishers observed to be inspected in October of 2022.

Facility observed to have designated entry point. Staff did not take LPA's temperature nor screen for symptoms. 30 day supply of PPE observed. All restrooms stocked with paper towels. Water temperature observed to be 114.4 degrees Fahrenheit. Hand washing signs observed in all bathrooms. Bathrooms did not have garbage cans with lids. Social distancing signs were not observed to be posted in the facility. No staff observed to be wearing masks during inspection.

No deficiencies cited during visit. Advisory notes issued. This report was reviewed with staff member Gina Sobrevilla and a copy of the signed report was provided. Report was provided electornically due to printer error
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022
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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