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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200234
Report Date: 03/23/2023
Date Signed: 03/23/2023 02:38:55 PM

Document Has Been Signed on 03/23/2023 02:38 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 HOMEFACILITY NUMBER:
435200234
ADMINISTRATOR:MENDOZA, AURORAFACILITY TYPE:
735
ADDRESS:2046 LAVONNE AVENUETELEPHONE:
(408) 272-0587
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY: 6CENSUS: 5DATE:
03/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Lourdes CeraTIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPAs) David Marrufo and Tracy Pham conducted an unannounced Required 1 Year visit and met with Lourdes Cera, House Manager.

During visit, LPAs toured the inside and outside of the facility. LPAs toured the facility kitchen and observed there to be a food supply of at least two days and a perishable food supply of at least 7 days. Sharps and medications were locked in secured areas. There was a first aid kit in the facility. LPAs observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

The facility bathroom had available soap and paper towels. The shower had grab bars and a shower chair. The water temperature was measured at 115 F.

Facility smoke detectors were tested and found to be functioning when tested. Three out of three resident bedrooms had available bedding, drawers, and functioning lights. However, resident R1's bedroom did not have a bed. Staff showed LPAs a mattress, blankets, and hammock in the outside rear porch area which they said R1 uses to sleep outside. LPAs spoke with Administrator Christia Mendoza who stated R1 has irregular sleeping hours and behaviors. She stated R1 will sleep outside at night on the mattress or hammock and sometimes bring the mattress in to sleep as well. LPAs observed that two out of two bedrooms had objects obstructing the sliding door exits.

LPAs reviewed facility records for staff and residents. LPAs reviewed resident medications and Personal and Incidental Money logs.

See LIC809-C for more information. Page 1 of 2.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2023
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
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 HOME
FACILITY NUMBER: 435200234
VISIT DATE: 03/23/2023
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LPAs observed that the Emergency Disaster Plan at the facility did not have a signature.

Advisory Notes were issued. See LIC9102 pages for more information.

No deficiencies were cited as per California Code of Regulations Title 22.


This report was reviewed with Lourdes Cera, House Manager, and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC809 (FAS) - (06/04)
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