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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200234
Report Date: 01/20/2022
Date Signed: 01/20/2022 04:54:10 PM

Document Has Been Signed on 01/20/2022 04:54 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SUNRISE HOMEFACILITY NUMBER:
435200234
ADMINISTRATOR:MENDOZA, AURORAFACILITY TYPE:
735
ADDRESS:2046 LAVONNE AVENUETELEPHONE:
(408) 272-0587
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY: 6CENSUS: 5DATE:
01/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Christia BasquezTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Steve Chang, licensing Program Manager (LPM) Sarah Yip, and Program Clinical Consultant (PCC) Helen Shi conducted Technical Assistant - PCC through tele-inspection (Zoom),and met with Administrator (ADM) Christia Basquez and Staff Lourdes Tera.

The purpose of this TA PCC Tele visit was to review the facility COVID-19 infection mitigation plan and conducted inspection of the facility to ensure plan is being carried out and to provide support and guidance to staff in mitigating the spread of virus.

During tele-visit inspection, a tour of the facility was conducted which started at the main entrance to check COVID-19 signage and screening procedures. The facility has the COVID-19 posters at the main entrance including screening questionnaire forms, hand sanitizer, face masks, thermometer, glove, and a visitor log book at the screening station.

The facility common areas were inspected such as the kitchen, living room/family room, dinning area, bathrooms were observed. There are 3 resident shared bedrooms, 1 staff live-in bedroom, 2 resident bathrooms, and one staff restroom in facility. Not all the trash cans were observed with covers. Paper towels with holders, and washing hands signs by the sinks were observed. Kitchen towel were observed in kitchen. Cloth towels were observed in the restrooms. The laundry room was observed and inspected. The resident bedrooms were observed. Backyard was observed and inspected. ADM stated the meals were not provided at dinning table in dinning rooms.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: SUNRISE HOME
FACILITY NUMBER: 435200234
VISIT DATE: 01/20/2022
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Based on today's inspection, the facility is being recommended the following:

1. Facility to have a bigger screening station to include having visitors do the checklist outside the door if weather permits.
2. Facility to frequently wipe and disinfect high touch areas.
3. Facility to have covered Trash cans with foot pedal in screening area, kitchen, and back patio visitation area.
4. Remove the Kitchen cloth towels after use and put them in laundry basket
5. Do not leave any cloth towel in restrooms.
6. Put N95 masks at screening station for visitors and staff if needed.
7. Screening questionnaires should have name, contact phone number and temperature.
8. Have visitors call facility in advance if possible and conduct a pre-screening.
9. The paper towels on restroom sinks should either be mounted on wall or hang on the towel bar as the paper towel is too close to the faucet.
10. Monitoring residents and staff for symptoms and change of condition and contact PCP immediately.
11. No need to do testing for 90 days; however; if symptoms occur, do PCR test.
12. Do a deep cleaning of all rooms, furniture, and common areas. Facility to check CDC web site for reference.
13. Use high temperature hot water for COVID positive residents’ laundry.

No deficiencies cited during today's Tele Visit. Exit interview conducted with Administrator.
A copy of this report emailed to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
LIC809 (FAS) - (06/04)
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