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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200806
Report Date: 12/07/2018
Date Signed: 12/22/2020 09:48:01 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 SUNNYVALEFACILITY NUMBER:
435200806
ADMINISTRATOR:BAGHERI, TAYEBEHFACILITY TYPE:
740
ADDRESS:633 S KNICKERBOCKER DRTELEPHONE:
(408) 749-8600
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:103CENSUS: 91DATE:
12/07/2018
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Gayle KellyTIME COMPLETED:
02:25 PM
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**This is amended report to redact confidential names only. No other statements have been amended.**

Licensing Program Analyst ( LPA) Anna Morales conducted an unannounced Case Management visit today and met with the Manager on Duty, Gayle Kelly.

The purpose of LPA's visit is to verify and confirm that the facility received the Immediate Exclusion Letter for employee, S1, and that S1 is no longer present at the facility.

Based on evidence obtained during today's visit, the LPA has verified the individual is not present, employed or residing at the facility. LPA has advised the licensee to disassociate the individual from their roster and submit an update LIC500. Verification of removal is complete.

Exit interview was conducted with Gayle Kelly.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 205-9562
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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