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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200234
Report Date: 05/04/2022
Date Signed: 05/04/2022 03:56:45 PM

Document Has Been Signed on 05/04/2022 03:56 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: 4DATE:
05/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Lourdes CeraTIME COMPLETED:
03:39 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with House Manager (HM) Lourdes Cera. Upon arrival, HM took LPA body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility inside out with HM. COVID posters were observed at main entrance and the facility. Screening station with masks, hand sanitizer, glove, thermometer and visitor log book was observed at the main entrance. Living room, kitchen, dinning room and two restrooms were inspected. Trash cans were observed without covers in the two restrooms. HM stated the facility will change the trash cans to be the trash cans with covers in 3 days. Paper towel were observed with holders. 5 bedrooms were observed in facility including 3 resident rooms, 1 spare room, and one staff room. Laundry room was inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. PPE supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 68 degree F, and hot water temperature was at 108 degree F in facility. Four residents and 2 staff were observed in facility.

Fire extinguisher was serviced on 03/30/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by HM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

HM stated all the residents and staff are fully vaccinated. No citation were noted today. Exit interview was conducted with HM. This report was provided to HM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2022
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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