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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708734
Report Date: 09/24/2024
Date Signed: 09/27/2024 10:50:23 AM


Document Has Been Signed on 09/27/2024 10:50 AM - 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: 5DATE:
09/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Lead Caregiver Gina SobrevillaTIME COMPLETED:
07:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Marcela Yanez and Simi Rai conducted an unannounced annual inspection visit. LPAs met with Lead Caregiver (S1) Gina Sobrevilla and stated the purpose of today's visit. S1 called Licensee/Administrator and left a message on voicemail. During the visit, LPA observed 2 staff and 5 residents present at the facility. LPAs observed 2 residents walking around the facility, including the kitchen and living room.

LPAs toured the facility inside and outside with S1 which included the Living room, kitchen, dining room, 2 bathrooms and 5 residents bedrooms and 1 staff room. LPAs observed 2 of 5 resident rooms (Bedroom #5 and #6) window screens are not in good repair wherein the screen is ripped in multiple area and the screen door in bedroom #5. LPAs observed a smoking area which staff S1 stated is used by residents. Behind the chair, LPAs observed more than 5 tools were on a table, not locked and accessible to the residents.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPAs observed 1 prescription medication in the refrigerator, located on the inside of the door, unlocked and accessible to residents. LPAs observed a cabinet in the kitchen which contained resident's medication was unlocked and accessible to residents. LPAs observed toxic chemicals under the kitchen sink including but not limited to 1 canister of Comet, 1 bottle of Bleach, 1 bottle of Dish soap.

LPAs observed 2 vents one located above electric stove in kitchen and one located in the hallway above garage door to be uncovered and has dust and grease.

Continuation on LIC 809-C, Page 1 of 2.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7


Document Has Been Signed on 09/27/2024 10:50 AM - It Cannot Be Edited

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: SUNRISE MANOR RESIDENTIAL CARE HOME
FACILITY NUMBER: 430708734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2024
Section Cited
CCR
87463(b)

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87463 (b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person.
This requirement is not met as evidenced by:

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Licensee/Administrator was not present during today's visit. Licensee/Administrator to submit a written plan of action understanding regulation and will ensure Appraisal/Needs and Services plans are created for residents by POC due date.
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Based on interview and record review, R2's Appraisal/Needs and Services Plan was not signed by R2 and/or R2's responsible party which poses a potential health, safety or personal rights risk to persons in care.
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Type B
10/01/2024
Section Cited
CCR87468(b)(1)(A)

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87468 (b)(1)(A)The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.
This requirement is met as evidenced by:
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Licensee/Administrator was not present during today's visit. Licensee/Administrator to submit a written plan of action understanding regulation and will ensure residents' file did not contain a signed Personal Rights of Residents in All Facilities by POC due date
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Based on interview and record review, R2's file did not contain a signed Personal Rights of Residents in All Facilities which poses a potential health, safety or personal rights risk to persons in care.
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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: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7


Document Has Been Signed on 09/27/2024 10:50 AM - It Cannot Be Edited

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: SUNRISE MANOR RESIDENTIAL CARE HOME
FACILITY NUMBER: 430708734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2024
Section Cited
CCR
87307(d)(6)

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87307(d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
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Licensee/ Administrator was not present during today's visit. Licensee/Administrator to submit a written plan of action understanding regulation and will ensure written plan to ensure all indoor and outdoor passageways and stairways are free from obstruction and schedule in-service training by POC due date.
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Based on observation and interview, the licensee did not ensure that sliding exit doors tracks were free of obstruction. LPAs observed a pole obstructing the sliding exit door tracks which poses an immediate health, safety or personal rights risk to persons in care.
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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: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 09/27/2024 10:50 AM - It Cannot Be Edited

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: SUNRISE MANOR RESIDENTIAL CARE HOME
FACILITY NUMBER: 430708734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2024
Section Cited
CCR
87303(c)

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87303 Maintenance and Operation (c) All window screens shall be clean and maintained in good repair.
This requirement was not met as evidenced by:
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Licensee/ Administrator was not present during today's visit. Licensee/Administrator to submit a written plan of action understanding regulation and will ensure window screens are clean and in good repair by POC due date.
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Based on observation, two window screens in resident's room and 1 door screen for exit door was not clean and not in good repair which poses a potential health, safety or personal rights risk to persons in care.
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Type B
10/01/2024
Section Cited
CCR87457(c)

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87457(c)Prior to admission ... shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria.
This requirement is not met as evidenced by:
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Licensee/Administrator was not present during today's visit. Licensee/Administrator to submit a written plan of action understanding regulation and will ensure Appraisal/Needs and Services plans are created for residents by POC due date.
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Based on interview and record review, the licensee did not comply with the section cited above when 1 out of 2 resident files did not create an Appraisal/ Needs and Services plan which poses a potential health, safety or personal rights risk to persons in care.
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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: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 09/27/2024 10:50 AM - It Cannot Be Edited

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: SUNRISE MANOR RESIDENTIAL CARE HOME
FACILITY NUMBER: 430708734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2024
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation
(a) 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 requirement is not met as evidenced by:
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Licensee/Administrator was not present during today's visit. Licensee/Administrator to submit a written plan of action understanding regulation and will ensure air vents are covered, clean and sanitary by POC due date.
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Based of observation, two air vents above the stove and in the hallway were not covered and filled with dust which poses a potential health, safety or personal rights risk to persons in care.
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Type B
10/01/2024
Section Cited
CCR87465(h)(6)

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87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
This requirement is not met as evidenced by:
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Licensee/Administrator was not present during today's visit. Licensee/Administrator to submit a written plan of action understanding regulation and will ensure centrally stored medications is recorded on the Centrally Stored Medication log by POC due date.
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Based on observation and record review, R1's 5 out of 10 centrally stored medications and R2's 6 out of 6 centrally stored medications were not recorded on the Centrally Stored Medication log which poses a potential health, safety or personal rights risk to persons in care.
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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: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
LIC809 (FAS) - (06/04)
Page: 5 of 7


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: SUNRISE MANOR RESIDENTIAL CARE HOME
FACILITY NUMBER: 430708734
VISIT DATE: 09/24/2024
NARRATIVE
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Page 2 of 2.

The knives storage area, and cleaning product storage area was locked and inaccessible to residents in care. Room temperature was at 83.4 degrees F, and hot water temperature in the bathroom sinks was ranged from 119.1 - 119.5 degrees F in both resident bathrooms.

Fire extinguisher observed in the kitchen was serviced in 10/25/2023. The facility was equipped with smoke and carbon monoxide detectors and in working condition. LPAs observed facility first aid kit and the last disaster drill was conducted on 07/24/2024.

LPA reviewed facility records for 2 staff and 2 residents. LPA reviewed 2 resident medications and centrally stored medication records. LPAs observed 5 out of 10 centrally stored medications for R1 and 6 out of 6 centrally stored medications was not recorded on centrally stored medication and destruction record. R2 Medication was not logged as well.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Licensee/Administrator was not present during exit interview. This report was reviewed with Lead Caregiver (S1) Gina Sobrevilla and a copy of the report was provided. Appeal Rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 09/27/2024 10:50 AM - It Cannot Be Edited

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: SUNRISE MANOR RESIDENTIAL CARE HOME
FACILITY NUMBER: 430708734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2024
Section Cited
CCR
87465(h)(2)

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87465 (h)(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement was not met as evidenced by:
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Licensee/ Administrator was not present during today's visit. Licensee/Administrator to submit a written plan of action understanding regulation and will ensure medications are stored inaccessible to residents and in-service training is scheduled by POC due date.
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Based on observation, 1 prescription medication was in the refrigerator unlocked and a drawer in the kitchen which contains resident's medication was unlocked and accessible to residents which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
09/25/2024
Section Cited
CCR87705(f)(1)

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87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
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Licensee/ Administrator was not present during today's visit. Licensee/Administrator to submit a written plan of action understanding regulation and will ensure tools are stored inaccessible to residents and in-service training is scheduled by POC due date.
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Based on observation, LPAs observed more than 5 tools were in the backyard, not locked and accessible to residents with Dementia poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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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: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
LIC809 (FAS) - (06/04)
Page: 7 of 7