435200806-6-29-2020-26-AS-SYIP-BRKKZK-20200716082048

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200806
Report Date: 05/28/2020
Date Signed: 06/29/2020 03:23:50 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/24/2020 and conducted by Evaluator Yatfai Ng

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20200324171003

FACILITY NAME:	SUNRISE OF SUNNYVALE		FACILITY NUMBER:	435200806
ADMINISTRATOR:	BAGHERI, TAYEBEH		FACILITY TYPE:	740
ADDRESS:	633 S KNICKERBOCKER DR		TELEPHONE:	(408) 749-8600
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	103	CENSUS: 81	DATE:	05/28/2020
		UNANNOUNCED	TIME BEGAN:	02:41 PM
MET WITH:	Tayebeh Tina Bagheri		TIME COMPLETED:	03:03 PM

ALLEGATION(S):

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Facility has mold.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced subsequent tele-complaint investigation to deliver the investigation finding due to current COVID-19 situation. LPA met with the Executive Director (ED) Tayebeh Tina Bagheri using FaceTime.

An initial unannounced tele-investigation was conducted by LPA on 3/31/2020. LPA virtually toured the facility, interviewed 2 staff, and obtain copy of environmental assessment report.

During the virtual tour on 3/31/2020, LPA observed that room 316 was under renovation. The paint on walls were smooth and bubble free. LPA did not see any sign of water damage or mold. LPA also virtually toured the stairwell next to room 316. The paint on walls of stairwell were also smooth and bubble free.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2020

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20200324171003

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNRISE OF SUNNYVALE	FACILITY NUMBER: 435200806
	VISIT DATE: 05/28/2020

NARRATIVE

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On 3/31/2020, 2 staff were interviewed. 2 out of 2 staff stated back in January 2020, there was a water overflow from room 412 down to room 316 causing damage to the walls in both rooms, and to the stairwell next to room 316. The facility took action by cleaning the affected areas. An independent company was contracted to assess the situation and to provide suggestions. The facility followed the recommendation by sanitizing molded areas, removing bubbled paints, and repainted the affected areas.

Based on record review, the Limited Visual & Moisture Assessment Report reveals that the facility contracted a private company to assess the water damage on 2/18/2020. The industrial hygienist from the said company went to the facility to assess the damage in room 316 and room 412 on 2/19/2020. The hygienist did not observe any mold in room 316 but observed “visible microbial-like staining on the bathroom vanity cabinet floor in Resident Unit 412.” The hygienist made recommendation to the facility after the assessment.

Based on record review, and interviews, the preponderance of evidence standard has been met; therefore, the allegation is found to be SUBSTANTIATED, which means that the allegation did occur.

A deficiency was cited today as per California Code of Regulations, Title 22. See 9099-D for more information. However, the facility had corrected the deficiency prior to tele-investigation.

This report and appeal rights were emailed to ED to review and to obtain signatures.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20200324171003

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNRISE OF SUNNYVALE	FACILITY NUMBER: 435200806
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/28/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/11/2020 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Licensee took action to address this issue by contracting a third-party independent company to assess the situation. Facility then hired workers cleaned, disinfected, and repainted the affected areas . Issue corrected prior to tele-visit.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews and record review: the facility had mold in residents’ rooms. This posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2020

LIC9099 (FAS) - (06/04)

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