430708734-9-24-2024-26-AS-RMAO-D9VUVJ-20241009155513

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430708734
Report Date: 09/24/2024
Date Signed: 09/24/2024 06:27:22 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
07/06/2023 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20230706162258

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:	05:30 PM
MET WITH:	Lead Staff, Gina Sobrevilla		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not in good sanitary conditions.
Staff neglected resident who was found in urine and feces.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
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 7/6/2023, the Department received a complaint with the above allegations. On 7/13/2023, the Department conducted an initial investigation at the facility.

Continuation on LIC 9099-C, Page 1 of 2.

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 2

Control Number 26-AS-20230706162258

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Page 2 of 2.

It was alleged on 2/12/2023 when R1 was transferred to the hospital, R1 was found in urine and feces and the R1’s room was not in good sanitary conditions.

On 7/13/2023, the Department interviewed staff S1 and ADM. ADM stated on 2/12/2023, R1’s conservator was notified regarding R1 refused to come out his/her bedroom for 2 days. ADM stated the floor was wet due to R1 continued to urinate in the continence pad for two days and refused staff to come into the room to assist. R1 would lock the door but staff had a key to open the lock. Staff called 911 on 2/12/2023 due to R1 had a unwitnessed fall in the room.

Based on review of progress notes from 11/4/2015 – 2/8/2023, R1 has a history of refusing assistance with incontinence care and shower.

Based on review of R1’s Physician’s Report dated 2/6/2017, R1 had neurocognitive impairment, bladder impairment and was confused/disoriented. Based on R1’s Appraisal/Needs and Services dated 2/10/2018, facility staff would motivate and encourage R1 for regular personal hygiene and cleanliness and remind R1 of bathing schedule. Based on documentation conversations between facility staff and R1’s conservator, R1 refused to be seen by R1’s doctor from 2021-2022.

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: 2 of 2