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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200234
Report Date: 05/06/2024
Date Signed: 05/07/2024 10:29:18 AM

Document Has Been Signed on 05/07/2024 10:29 AM - 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/
DIRECTOR:		MENDOZA, AURORAFACILITY TYPE:
735
ADDRESS:2046 LAVONNE AVENUETELEPHONE:
(408) 272-0587
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY: 6CENSUS: 5DATE:
05/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:10 PM
MET WITH:Lourdes Cera - House ManagerTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced Required 1 Year visit and met with Lourdes Cera, House Manager (HM). HM stated the administrator (ADM) Christia Marie Mendoza-Vasquez was not present in the facility.

During visit, LPA toured the inside and outside of the facility, including kitchen, dining room, living room, 2 staff room, 3 resident bedrooms, 2 bathroom and laundry room. LPA observed that the kitchen was organized and sanitary. LPA observed that the kitchen stove was missing and observed a butane portable cook top. HM stated that the cook top is what they use temporarily while ADM purchases a new one to replace the broken stove. HM stated stove broke this morning (5/6/2024).

LPA observed two days of perishable and 7 days of non-perishable food supply. Sharps and medications were locked in secured areas. LPAs observed locked and secured areas for the cleaning supplies and laundry detergents. Fire extinguisher located in the kitchen was recently inspected on 3/19/2024.

The facility bathroom had available soap. LPA observed that paper towel was missing. The shower had grab bars and a shower chair. The water temperature was measured at 113.3 degree F.

Facility smoke and carbon monoxide detectors were tested and found to be functioning when tested. Three out of three resident bedrooms had available bedding, drawers, and functioning lights. LPA observed a hammock, a mattress on the covered back porch and blankets hanging on the clothes line. HM stated that resident R1's uses the hammock and prefers to sleep at the covered back porch rather than the bedroom. R1s bedroom have a bed with air mattress. HM showed. HM and Staff (S1) stated that R1 will sleep in the bedroom for a few minutes, but will get up and go to the covered back porch to sleep. HM and S1 stated R1 will sleep outside at night. HM stated that R1 has irregular sleeping patterns. R1 will not sleep for 2 to 3 nights in a week. page 1 of 2
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
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 2
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: 05/06/2024
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LPA toured the exterior perimeter of the facility with HM and found no obstructions on the walkways on both sides of the building. Sliding doors are working properly and no obstruction was observed.

During the visit, LPA observed 3 out 5 resident, 2 out of 5 were out of the facility. 2 out of 5 was resting and 1 out of 5 was in the living area. 5 staff was in the facility. 2 out of 5 are on duty. 1 out of 5 is scheduled for the NOC shift.

LPA requested a copy of the LIC 500 and LIC 308, Administrator certificate, staff schedule and resident roster.

Due to time constraints, the annual inspection will need to be continued at a later date.
No deficiencies were cited at this time as per California Code of Regulations Title 22.
This report was reviewed with House Manager Lourdes Cera and a copy of this report was provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC809 (FAS) - (06/04)
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