430708734-9-24-2024-26-AS-RMAO-D9VURF-20241009154842

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430708734
Report Date: 09/24/2024
Date Signed: 09/24/2024 06:26:28 PM

Unsubstantiated

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
06/05/2023 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20230605152553

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:	09/24/2024
		UNANNOUNCED	TIME BEGAN:	05:00 PM
MET WITH:	Lead Staff, Gina Sobrevilla		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Food served is not stored at appropriate temperature.
Facility bathroom shower mat and curtain have mold.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Simi Rai and Marcela Yanez conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Lead Staff, Gina Sobrevilla and stated the purpose of today’s visit.

On 6/5/2023, the Department received a complaint with the above allegations. On 6/13/2024, the Department conducted an initial investigation at the facility.

Continuation on LIC 9099-C, Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
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.

LIC9099 (FAS) - (06/04)

Page: 1 of 6

Control Number 26-AS-20230605152553

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: 09/24/2024

NARRATIVE

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Page 2 of 3.
Food services is not stored in at appropriate temperatures.
On 6/13/2023, the Department interviewed 5 residents (R1-R5). One resident refused to answer questions related to the allegation. Four out of four resident stated they have no complaints or issues about the food temperature when served to the residents. R1 stated he/she is particular with the food and it is never served at cold temperature but if there was an issue, R1 would let staff know for assistance.

On 6/13/2023, the Department interviewed 2 staff (S1-S2). Two out of two staff stated the staff serve the residents warm food and they keep the food warm with the microwave. S1 and S2 stated they will warm/heat the food if residents had a concern.

During visit on 6/13/2023, LPA tested the microwave and there are no issues with the microwave.

On 6/13/2023, the Department interviewed former resident (F1) and witness (W1). F1 stated the staff would cook 1 items at time and they plated the food as each item was being cooked so when the food was served to the residents, some items were not warm anymore. F1 did notify the staff but F1 did not request for the food to be warmed. W1 stated the food was pretty good when W1’s resident moved into the facility, but it was repetitive and breakfast would be served cold.

Facility bathroom shower mat and curtain have mold.
On 6/13/2023, the Department interviewed 5 residents (R1-R5). One resident refused to answer questions related to the allegation. Four out of four residents stated they have not observed mold on the shower mat or shower curtain.

On 6/13/2023, the Department interviewed 2 staff (S1-S2). Two out of two staff stated there is no mold on the shower mat and shower curtains. S1 stated 4 out of 5 residents take sponge baths in bed and 2 out of 5 residents prefer to take a shower in the bathroom and staff will assist with the shower. S2 stated the shower mat and shower curtain was replaced due the items being old due to normal wear and tear.

During visit on 6/13/2023, LPA observed 2 out of 2 bathrooms and LPA did not observe any mold on shower curtains. LPA did not observe shower mats since the residents use shower chair.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
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

LIC9099 (FAS) - (06/04)

Page: 6 of 6

Control Number 26-AS-20230605152553

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: 09/24/2024

NARRATIVE

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Page 3 of 3.

On 6/13/2023, the Department interviewed former resident (F1) and witness (W1). F1 stated the shower mat would have mold on the suction cups and would be placed on the grab bars but the shower mats were cleaned. F1 did not say anything about shower curtains having mold. W1 stated one of the bathrooms had mold, but did not specify which bathroom and did not observe mold on the shower curtains.

Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Lead Staff, Gina Sobrevilla and a copy of the report was provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
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

LIC9099 (FAS) - (06/04)

Page: 5 of 6

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
06/05/2023 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20230605152553

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:	09/24/2024
		UNANNOUNCED	TIME BEGAN:	05:00 PM
MET WITH:	Lead Staff, Gina Sobrevilla		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Residents are left unsupervised by staff.
Facility kitchen floor has a hole.
Facility shower knob does not have a valve for hot water, so water is either scalding hot or lukewarm.

INVESTIGATION FINDINGS:

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3
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5
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13

Licensing Program Analysts (LPAs) Simi Rai and Marcela Yanez conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Lead Staff, Gina Sobrevilla and stated the purpose of today’s visit.

On 6/5/2023, the Department received a complaint with the above allegations. On 6/13/2024, the Department conducted an initial investigation at the facility.

Continuation on LIC 9099-C, Page 1 of 3.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
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.

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 26-AS-20230605152553

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: 09/24/2024

NARRATIVE

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Page 2 of 3.
Residents are left unsupervised by staff.
On 6/13/2023, the Department interviewed 5 residents (R1-R5). One resident refused to answer questions related to the allegation. Four out of four residents stated they do not recall a time when there was no staff present in the facility. R1 stated he/she does not ask for assistance. R4 stated he/she needs assistance and staff are able to assist him/her when required.

On 6/13/2023, the Department interviewed 2 staff (S1-S2). Two out of two staff stated there are always two staff at the facility. S2 stated when staff need to go to the bank, then there will be at least one staff at the facility for a short moment.

During visit on 6/13/2023, LPA observed two staff at the facility, overseeing 5 residents present at the facility.
On 6/13/2023, the Department interviewed former resident (F1) and witness (W1). F1 stated it happened twice when staff S3 told F1 that there was no one working at the facility and S3 just arrived at the facility for his/her shift. F1 cannot recall the specific dates. W1 stated he/she observed frequently there was one staff present at the facility and two staff present at the facility in the day time.

Facility kitchen floor has a hole.
On 6/13/2023, the Department interviewed 5 residents (R1-R5). Two residents refused to answer requested related to the allegation. Three out of three residents stated they have observed no holes on the kitchen floor.
On 6/13/2023, the Department interviewed 2 staff (S1-S2). Two out of two staff stated they have not observed a hole on the kitchen floor. S1 and S2 have been a caregiver for 9 years at the facility and not observed a hole in the kitchen floor.

During visit on 6/13/2023, LPA observed the kitchen and the kitchen floor. LPA did not find any holes on the kitchen floor.

On 6/13/2023, the Department interviewed former resident (F1) and witness (W1). F1 stated he/she did not observe a hole on the kitchen floor. W1 stated he/she did not observe a hold in the kitchen floor.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
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

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 26-AS-20230605152553

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: 09/24/2024

NARRATIVE

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Page 3 of 3.
Facility shower knob does not have a valve for hot water, so water is either scalding hot or lukewarm.
On 6/13/2023, the Department interviewed 5 residents (R1-R5). One resident refused to answer questions related to the allegation. Four out of four residents stated they are able to adjust the heat of the shower water with the shower knob.

On 6/13/2023, the Department interviewed 2 staff (S1-S2). Two out of two staff stated the water temperature in the bathroom shower can be adjusted and they use the shower knob to adjust the water temperature. S1 stated two residents need assistance with showers and they are able to use the shower knob without issue. S2 stated they replaced the shower knob 6 months ago due to normal wear and tear.

During visit on 6/13/2023, LPA observed 2 out of 2 bathrooms and both bathrooms have a valve for hot water. LPA tested water temperature in bathroom #2 since this is the bathroom residents use for showers and water temperature ranged from 98 degrees F to 122 degrees F. LPA observed the shower knob can be turned left and right.

On 6/13/2023, the Department interviewed former resident (F1) and witness (W1). F1 stated he/she liked hot showers, and the water was either scalding hot or lukewarm wherein the water would change within 30 seconds. W1 stated he/she did not know if there was anything wrong with the shower, but there was a problem with the water and there was a new valve placed in the shower.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Lead Staff, Gina Sobrevilla and a copy of the report was provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
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

LIC9099 (FAS) - (06/04)

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