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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708734
Report Date: 07/13/2026
Date Signed: 07/13/2026 02:30:33 PM

Document Has Been Signed on 07/13/2026 02:30 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/
DIRECTOR:		AIDA MIRANDAFACILITY TYPE:
740
ADDRESS:790 & 792 LOS PADRES BLVD.TELEPHONE:
(408) 615-0999
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY: 6CENSUS: 5DATE:
07/13/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Licensee/Administrator, Aida MirandaTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai and Licensing Program Manager (LPM) Romeo Manzano conducted an unannounced case management visit to deliver a Decision and Order letter on behalf of the Department. LPA and LPM met with Licensee/Administrator, Aida Miranda and stated the purpose of today's visit. LPA Rai observed 5 residents and 2 staff at the facility.

During visit, LPA Rai handed the Decision and Order letter to Aida Miranda directly. Aida verbalized receiving the letter via certified mail last week, 07/10/2026. Licensee stated that she has not opened certified letter upon receipt on 7/10/26 assuming it was regarding her civil penalty invoice. Aida stated she was not aware what the mail was about.

During today's visit, LPA Rai amended the case management visit conducted on 07/01/2026. Deficiencies were advertently cited and civil penalty will no longer be assessed. However, Technical Assistance (TA) was provided to ensure facility files are kept in tact.

During visit, LPA and LPM observed a 7-day medication container for 3 residents located on the top of the dining room table, in accessible to residents in care. S1 & S2 stated they pre-pour 2 days of medications at a time for resident (R1). LPA and LPM advised staff and Licensee/Administrator to ensure medications were not pre-poured in case resident's physician were to change prescription orders.

Continuation on LIC 809-C, Page 1 of 2.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Simranjit Rai
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2026
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 5
Document Has Been Signed on 07/13/2026 02:30 PM - It Cannot Be Edited


Created By: Simranjit Rai On 07/13/2026 at 12:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/20/2026
Section Cited
CCR
87626(a)(1),(b)(1-3)

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87626 Contractures (a) (1) If the contractures do not severely affect functional ability and the resident is able to care for the contractures by him/herself.
This requirement is not met as evidenced by:
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Licensee/Administrator to submit a written plan of action to ensure R1's contractures are addressed in the Appraisal/Needs and Services Plan and obtain written documentation by the appropriately skilled professional by POC due date.
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Based on interview and record review, Licensee did not ensure there was an Appraisal/Needs and Services Plan address R1's contractures or written documentation by the appropriately skilled professional due to resident R1 has contractures on both hands which poses/posed a potiential health,
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(con't) safety and/or Personal Rights risk of residents in care.
Type B
07/20/2026
Section Cited
CCR87465(h)(5)

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:
(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
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Licensee/Administrator to submit a written plan of action to ensure resident's medications are not stored outside of the originally received container by POC due date.
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This requirement is not met as evidenced by:
Based on interview and observation, Licensee did not store resident's medication in its original container and staff were using 7-day pill box to store resident's medications which poses/posed a potiential health, safety and/or Personal Rights risk of residents in
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(con't) care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Simranjit Rai
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2026


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/13/2026 02:30 PM - It Cannot Be Edited


Created By: Simranjit Rai On 07/13/2026 at 12:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/20/2026
Section Cited
CCR
87608(a)(5)(B)

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87608 Postural Supports (a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This requirement is not met as evidenced by:
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Licensee/Administrator to submit a written plan of action to follow physician's order for half-bed rail and ensure staff are not using full-bed rail by POC due date.
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Based on interview and records reviewed, resident R1 has an physician's order for half-bed rail, but staff is still using full bed rail at night which poses/posed a potential health, safety and/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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Simranjit Rai
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 07/13/2026
NARRATIVE
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Page 2 of 2.
LPA and LPM observed resident (R1) in bed with full bed rails attached to the hospital bed. R1 has an order for half-bed rails. Staff S1 and S2 admitted that they use the full bed rail at night. The Department does not have exception in place for R1. LPA and LPM observed R1 to have contractures on both hands and the Appraisal/Need and Services Plan did not address the contractures.

During inspection, LPA and LPM observed a container of rice on the floor. LPA/LPM suggested for staff to separate the staff food from resident food, in case the resident were to consume food in the kitchen. Food that are provided from free pantry services should not be consumed by residents in care. Food containers should not be on the floor even if in a container due to risk of contamination.

LPA and LPM observed 3 and half bread loafs in a bag on top of the fridge and there was mold on the bread. LPA and LPM observed mold growing all over the loafs. LPA and LPM observed grime inside the racks in the fridge. S2 stated that clean the fridge once a week.

Licensee/Administrator Aida Miranda addressed the ramp leading to the front door of the facility. She stated the maintainence employee was informed and will fix the ramp. The ramp is able to use for now and needs to be maintained.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. During today's visit, repeat deficiencies were cited for the following California Code of Regulations, Title 22: CCR 87608(a)(5)(B). A civil penalty of $250 will be assessed for 1 repeat violation within 12 months of the initial citation. If the deficiency is not corrected by POC due date, an additional $100 will be assessed until the deficiency is corrected. Please see LIC421FC.

This report was reviewed with Licensee/Administrator, Aida Miranda and a copy of the report was provided. Appeal Rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Simranjit Rai
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2026
LIC809 (FAS) - (06/04)
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