435200694-4-27-2023-26-AS-MMOR-CRAT7B-20230427142828

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200694
Report Date: 04/27/2023
Date Signed: 04/27/2023 02:28:58 PM

Document Has Been Signed on 04/27/2023 02:28 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 MANOR II		FACILITY NUMBER:	435200694
ADMINISTRATOR:	AIDA MIRANDA		FACILITY TYPE:	740
ADDRESS:	2536 AUSTIN PLACE		TELEPHONE:	(408) 249-1149
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95050
CAPACITY:	6	CENSUS: 4	DATE:	04/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:41 AM
MET WITH:	house manager Gina Sobrevilla		TIME COMPLETED:	02:40 PM

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	Licensing Program Analysts (LPAs) Simi Rai and Manuel Monter conducted an unannounced Required 1 Year visit and met with house manager Gina Sobrevilla (S1). During the beginning of the visit, S1 called licensee Aida Miranda and verbally gave permission for S1 to sign documents. LPAs toured the inside and outside of the facility. LPAs toured the facility kitchen and observed food supply of at least 2 days of perishable food supply and at least 7 days of nonperishable food supply. 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, paper towels. S1 stated the residents are not able to function a trash can will lid, therefore the facility staff will remove trash from both bathrooms in the morning and evening. The shower had grab bars, non-skid mats, and a shower chair. The water temperature in the bathroom sinks and showers ranged from 117.1 degrees Fahrenheit to 119.5 degrees Fahrenheit. The water temperature in the kitchen sink was 119.5 degrees Fahrenheit. One fire extinguishers were observed and was inspected on October 2022. Facility smoke detectors were tested and found to be functioning condition. Five out of five resident bedrooms had available bedding, drawers, and functioning lights. While touring the outside area of the facility, the exits were cleared of obstruction. LPAs conducted interviews with 3 residents and 2 staff. Page 1 out of 2, see 809-C.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

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 10

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 MANOR II	FACILITY NUMBER: 435200694
	VISIT DATE: 04/27/2023

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

LPAs reviewed facility records for two staff and four residents. LPAs observed for R1's resident file did not contain a pre-placement appraisal and appraisal/needs and services plan. LPA's observed R1's resident file did not contain Personal Rights of Residents in All Facility's form and initial Personal Property Inventory. Per S1, R1's family still has part of the file with them. S1 called R1's family to obtain residents file during LPA's visit.

LPAs reviewed resident medications and central stored medication records. LPA's observed 4 out of 4 resident files did not contain physician's orders for the medications administered by staff in the facility. LPAs observed R1's medication in a locked cabinet in R1's room which R1's family and facility staff have access to by a key.

Advisory Notes and Technical Violation were issued. See LIC9102 pages for more information.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.

This report was reviewed with house manager Gina Sobrevilla and a copy of the report was provided. Appeal Rights were provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

Page: 9 of 10

Document Has Been Signed on 04/27/2023 02:28 PM - It Cannot Be Edited

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 MANOR II	FACILITY NUMBER: 435200694
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(e)

87465 Incidental medical and dental care (e) for every prescription and non prescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 3 out of 4 resident files did not contain a physican order's for the medication which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/04/2023
	Plan of Correction
1 2 3 4	Licensee will submit signed medication list for all resident and email to LPA by POC date. Licensee will provide a written plan to ensure all residents files contains physican's orders for prescription and non prescription PRN medications.

Type B

Section Cited

CCR

87457(c)

87457 Pre Admission Appraisal- General (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above when out 1 of 4 resident files did not contain pre admission appraisal as well as the needs and services plan which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/04/2023
	Plan of Correction
1 2 3 4	Licensee will complete appriasal / needs and services plan with residents POA and send to LPA by POC date. Licensee will provide a written plan for admission procdures for all new residents and will submit to LPA.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

Page: 5 of 10

Document Has Been Signed on 04/27/2023 02:28 PM - It Cannot Be Edited

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 MANOR II	FACILITY NUMBER: 435200694
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468(b)(1)(A)

87486 Personal Rights (b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities or and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. (A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review the licensee did not comply with the section cited above in 1 out of 4 resident files did not contain a signed copy of Personal Rights of Residents in All Facilities which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/04/2023
	Plan of Correction
1 2 3 4	Licensee will submit a copy of R1's Personal Rights of Residents in All Facilities and send to LPA by POC date. Licensee will submit a written plan on admission procedures to LPA.

Type B

Section Cited

CCR

87218(a)(1)

87218 Theft and Loss (1) The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 4 resident files did not contain the initial personal property inventory which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/04/2023
	Plan of Correction
1 2 3 4	Licensee will submit a copy of R1's personal property inventroy to the LPA by POC date. Licenseee will submit to LPA admission procedures for new residents.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

Page: 6 of 10