435200694-4-12-2024-26-AS-KHOS-D4KNQ3-20240422103915

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200694
Report Date: 04/11/2024
Date Signed: 04/12/2024 08:10:38 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/01/2022 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20220701103507

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: 5	DATE:	04/11/2024
		UNANNOUNCED	TIME BEGAN:	12:38 PM
MET WITH:	House Manager, Gina Sobrevilla		TIME COMPLETED:	12:39 PM

ALLEGATION(S):

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The facility allowed individuals with no fingerprint clearance to reside and/or work in the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the House Manager, Gina Sobrevilla and stated the purpose of today’s visit.

On 7/1/2022 the Department received a complaint with the above allegations. It was alleged that an individual (F1) had been living at the facility for a month and has not been Criminally Record cleared.

On 7/8/2022, the Department conducted interview with Reporting Party (RP), who heard someone mentioned at a social gathering that F1 was living at the facility.

On 7/8/2022, the Department conducted an initial investigation at the facility. LPA interviewed 1 staff and observed 5 resident rooms.

Continuation on LIC 9099-C, Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 26-AS-20220701103507

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/11/2024

NARRATIVE

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Page 2 of 2.

On 7/8/2022, Staff (S1) stated F1 has not stayed in the facility and has not seen a staff not Criminally Record cleared live in the facility. 5 out of 5 residents were not able to state if F1 was living at the facility.

Based on record review of facility LIC 500 Personnel Report dated 03/30/2018 – 07/08/2022, F1 was not mentioned on the report as staff. Based on record review of LIC 9020 Register of Facility Clients/Residents dated 12/14/2028, F1 was not mentioned on the report as resident. Based on record review of LIS536 Facility Personnel Report Summary dated 7/8/2022, F1 was not associated to the facility as staff

Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2