435200234-10-8-2024-26-AS-KHOS-DA5NS9-20241017104246

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200234
Report Date: 10/08/2024
Date Signed: 10/08/2024 04:43:38 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
08/23/2023 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20230823113725

FACILITY NAME:	SUNRISE HOME		FACILITY NUMBER:	435200234
ADMINISTRATOR:	MENDOZA, AURORA		FACILITY TYPE:	735
ADDRESS:	2046 LAVONNE AVENUE		TELEPHONE:	(408) 272-0587
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95116
CAPACITY:	6	CENSUS: 5	DATE:	10/08/2024
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Christia Mendoza		TIME COMPLETED:	09:51 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not ensure a client is being properly fed while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with Administrator(ADM) Christia Mendoza.

On 08/23/2023, the Department received a complaint with the allegations that staff do not ensure a client is being properly fed while in care.

On 08/24/2024, the Department conducted an initial investigation visit. LPA interviewed ADM and staff.

LPA requested resident roster, personnel report LIC500, resident physician report, appraisal needs and service plan, and Centrally Stored Medication Record.

Continue on LIC9099-C. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

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 8

Control Number 26-AS-20230823113725

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 HOME	FACILITY NUMBER: 435200234
	VISIT DATE: 10/08/2024

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

Staff do not ensure a client is being properly fed while in care:
The allegation is that staff do not ensure a client is being properly fed.

On 8/24/2023, LPA interviewed ADM and staff S1. Both stated 2 residents usually eat meals in the dining room. 1 resident usually eats meals in the living room and 1 resident usually eats at the patio table. Both stated resident R1 usually eats meals in his/her room. Both stated caregivers always check around 20 minutes after meals were delivered to R1. Both stated If there was food still left on the plate, caregivers asked R1 if he/she wanted to continue to eat. Caregivers usually gave R1 more time to finish the meals if R1 stated he/she wants to continue. Both stated caregivers always asked R1 if he/she needs other food if R1 refused to continue on the meals. Both stated sometimes R1 refused breakfast or lunch, and caregivers gave R1 more time and asked again later. Caregivers offered other alternative food if R1 still refused the meals. ADM stated R1 has the personal rights to refuse the food and caregivers are not to force R1 to eat. Both stated the facility provides 3 meals and snacks to residents.

On 9/30/2024, LPA interviewed resident R1. R1 stated the food is not enough for him. R1 stated he/she requested more food, but nothing improved.

LPA interviewed 4 other residents. 4 out of 4 residents were unable to answer questions.

LPA interviewed staff S1. S1 stated the facility offers food in good amount for the meals. S1 stated the residents always cannot finish all the food for the meals.

LPA interviewed House Manager (HM). HM stated the facility provides meals in good amount and residents can request more food if they need more. HM stated R1 never requested more food. HM stated resident R1 claimed hungry because R1 wants the family to visit them more often. LPA interviewed ADM. ADM stated the facility provides sufficient food to residents. ADM stated resident R1 claimed hungry because R1 wants the family to visit them more often or to bring some food for them.

LPA checked the facility food supplies, and observed the perishable food supplies are sufficient for 2 day and non perishable food supplies are sufficient for 7 days.
Based on the interviews, no evidence to indicate that staff do not ensure a client is being properly fed.
Continue on LIC9099-C. Page 2 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

LIC9099 (FAS) - (06/04)

Page: 8 of 8

Control Number 26-AS-20230823113725

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 HOME	FACILITY NUMBER: 435200234
	VISIT DATE: 10/08/2024

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

Based on the investigation, observation, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

No citations noted for today’s visit. Exit interview was conducted with ADM. A copy of this report was provided to ADM.

Page 3 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 8