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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200694
Report Date: 04/11/2024
Date Signed: 04/11/2024 12:46:21 PM


Document Has Been Signed on 04/11/2024 12:46 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 IIFACILITY NUMBER:
435200694
ADMINISTRATOR:AIDA MIRANDAFACILITY TYPE:
740
ADDRESS:2536 AUSTIN PLACETELEPHONE:
(408) 249-1149
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY:6CENSUS: 5DATE:
04/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:House Manager, Gina SobrevillaTIME COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with House Manager (HM) Gina Sobrevilla. LPA Rai observed 3 staff and 5 residents at the facility.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

LPA Rai toured the resident bedrooms and staff room. 5 Out of 5 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sink was 108.4 degrees F. The water temperature in the kitchen sink was 108.6 degrees F. Fire extinguisher was observed and inspected on 10/25/2023. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drill was conducted on 03/18/2024.

LPA Rai reviewed facility records for 2 staff and 2 residents. LPA observed 2 out of 2 resident files did not contain weight records and physician's order for half bed-rails. LPA Rai confirmed with HM that these 2 residents (R1-R2) were not on Hospice services. 1 Out of 2 (R2) resident files did not contain Needs and Services Plan and R2 has been admitted to the facility since 3/1/2023.
LPA observed 2 out of 2 staff files not containing training on suspected abuse or reporting abuse in the facility or SOC341A, the Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults And Elders. The facility received Technical Violation on 4/27/2023.
Continuation on LIC 809-C, Page 1 of 2.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (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.

LIC809 (FAS) - (06/04)
Page: 1 of 5


Document Has Been Signed on 04/11/2024 12:46 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: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87466

87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 2 resident files reviewed did not contain weight log and House Manager stated they do not monitor the weight of the resident which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
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House Manager stated to submit a written plan of action understanding regulation and will ensure staff will initiate observing residents's weight by weight machine or measurement of the limbs (arm or leg) by POC due date. House Manager agreed and understood.
Type B
Section Cited
CCR
87608(a)(3)
87608 Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review and interview, the licensee did not comply with the section cited above in 2 out 2 residents (R1-R2) used half bed rails but did not have a written order from physician in the resident's record which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
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House Manager stated to submit a written plan of action understanding regulation and will ensure staff will obtain a written order from physiican in the resident's record for resident using half bedrails by POC due date. House Manager agreed and understood.
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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 04/11/2024 12:46 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: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on interview and record review, the licensee did not comply with the section cited above when out 1 of 2 (R2) resident files did not contain needs and services plan which poses a potential health, safety or personal rights risk to persons in care. House Manager and S1 stated the resident does they do not have R2's Appraisal/Needs signed at this time and R2 has been admitted to the facility since 3/1/2023.
POC Due Date: 04/18/2024
Plan of Correction
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House Manager stated 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. House Manager agreed and understood.
Type B
Section Cited
CCR
87506(b)(14)
87506 Resident Records
(b) Each resident’s record shall contain at least the following information:
(14) Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in1 out of 4 resident files did not contain centrally stored medication list, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
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House Manager stated will complete a written plan of action understanding regulation and completing Centrally Stored Medication Log by POC due date. House Manager agreed and understood.
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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
LIC809 (FAS) - (06/04)
Page: 3 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 MANOR II
FACILITY NUMBER: 435200694
VISIT DATE: 04/11/2024
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LPA Rai reviewed resident medications and central stored medication records. LPA observed 1 out of 4 resident files did not contain centrally stored medication list. Per HM, family of R1 handles all medications and medications are in a locked cabinet in R1's room. Only R1's family and facility staff have access to lock cabinet in R1's room. Facility has record of 3 out of 4 resident files to have centrally stored medication list. HM acknowledges that the facility should have record of the medication in R1's room even if R1's family would like to administer the medication. The facility received Technical Violation on 4/27/2023.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. This report was reviewed with House Manager (HM) Gina Sobrevilla and a copy of the report was provided. Appeal Rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (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
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 04/11/2024 12:46 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: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
15655
§15655 Training on elder and dependent adult abuse; long term health care facility, community care facility and residential care facility for the elderly; facility review
(a)(1) Each long-term health care facility, as defined in Section 1418 of the Health and Safety Code, community care facility, as defined in Section 1502 of the Health and Safety Code, or residential care facility for the elderly, as defined in Section 1569.2 of the Health and Safety Code, that provides care to adults shall provide training in recognizing and reporting elder and dependent adult abuse, as prescribed by the Department of Justice. The Department of Justice shall, in cooperation with the State Department of Health Services and the State Department of Social Services, develop a minimal core training program for use by these facilities. As part of that training, long-term care facilities, including nursing homes and out-of-home care facilities, shall provide to all staff being trained a written copy of the reporting requirements and a written notification of the staff's confidentiality rights as specified in Section 15633.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in 2 out of 2 staff files did not contain SOC341A, the Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults And Elders which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
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House Manager printed out SOC341 and 2 staff (S1 and S2) filed out the report during today's visit. House Manager will provide a written plan of understanding the regulations by POC due date. House Manager agreed and understood.

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 ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5