435200806-3-4-2025-26-AS-KHOS-DFHQLQ-20250407121620

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200806
Report Date: 03/04/2025
Date Signed: 03/04/2025 02:42:56 PM

Unfounded

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
11/20/2024 and conducted by Evaluator Kiran Jain

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20241120134458

FACILITY NAME:	SUNRISE OF SUNNYVALE		FACILITY NUMBER:	435200806
ADMINISTRATOR:	JAIRUS CABUENA		FACILITY TYPE:	740
ADDRESS:	633 S KNICKERBOCKER DR		TELEPHONE:	(408) 749-8600
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	103	CENSUS: 73	DATE:	03/04/2025
		UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Beena Kumar		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Factility neglect led to serious bodily injury

INVESTIGATION FINDINGS:

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On March 04, 2025, at 1:55 PM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to deliver the findings of a Complaint Investigation. Upon arrival, the LPA was greeted by the Executive Director (ED), Beena Kumar. The LPA disclosed the purpose of the visit. The ED informed the LPA that there were (73) residents in care.

On 11/20/2024, the Department received a complaint with allegation that “Facility neglect led to serious bodily injury”.

On 11/21/2024, the initial complaint investigation was conducted at the facility. The following documents were obtained: 1) LIC 602 Physicians Report, 2) Needs and Service plan, 3) Progress Notes, 4) Resident Roster, 5) Resident face sheet, 6) LIC 624 unusual incident report, 7) Staffing schedule, and 8) Hospice visit note reports.

Continued on LIC9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran Jain	TELEPHONE: (650) 416-4836
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

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-20241120134458

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 OF SUNNYVALE	FACILITY NUMBER: 435200806
	VISIT DATE: 03/04/2025

NARRATIVE

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Based on the review of the medical records from Hospice, on November 15, 2024, at 04:11 AM, facility caregiver (S1) contacted hospice to report that R1 had cut their left leg on a bed rail. S1 described the wound as “large,” approximately the size of a dollar bill, with bone exposure, bleeding, and pain. Hospice registered nurse (RN1) arrived at the facility to assess the wound. Upon examination, RN1 observed a deep abrasion with bone protrusion and oozing, necessitating stitches or sutures. Emergency Medical Technician (EMT) services were contacted, and R1 was transported to the hospital for further evaluation and treatment. Later that evening, R1 was discharged from the hospital and returned to the facility.

Based on review of progress notes for November 15, 2024, R1 sustained a laceration to the left shin after tangling their legs in the bed rails around 03:30 AM. Hospice was called, and the hospice nurse determined that it was necessary for R1 to be transferred to the hospital.

Based on the review of the Unusual Incident Report, during rounds, S1 observed R1 appearing restless and noted that R1 had sustained a laceration to the left shin. Hospice was notified, and R1 was subsequently sent to the hospital. R1 returned later the same day after the hospital treated the shin injury.

Based on the interview with five (5) facility staff members, 5 of 5 staff members (ED, S1, S2, S3, and S4) confirmed that R1 had a preexisting right shin injury, which was superficial and did not involve bone exposure. Hospice had been providing regular wound care, and staff reported no concerns regarding soilage, odor, or infection. Staff also confirmed that the left leg injury, which involved bone and tissue exposure, occurred on the same day as the incident. Staff stated that they immediately contacted hospice and arranged for R1’s hospital transfer.

Based on the interview with R1’s power of attorney (POA), the POA corroborated the staff’s statements. The POA stated that they visited R1 three times a week, every Monday, Wednesday, and Friday, and had not noticed any new leg wounds during their visit on Wednesday, November 13, 2024. The POA believed that the left leg injury occurred on November 15, 2024, and confirmed that no other leg injuries involving bone or tissue exposure had been observed prior to the incident. The POA believed that the injuries resulted from R1 getting their legs stuck in the bed rails. The POA did not express any concerns regarding abuse or neglect at the facility.

Continued on LIC9099-C

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran Jain	TELEPHONE: (650) 416-4836
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20241120134458

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 OF SUNNYVALE	FACILITY NUMBER: 435200806
	VISIT DATE: 03/04/2025

NARRATIVE

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Based on records reviewed and interviews conducted, the department has determined that the allegation is false, could not have happened, and/or is without a reasonable basis. Therefore, the allegation is UNFOUNDED.

No deficiencies were cited under the California Code of Regulations, Title 22.

An exit interview was conducted with the Executive Director. A copy of this report was discussed and left with the Executive Director, Beena Kumar, whose signature on this form confirms receipt of this report.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran Jain	TELEPHONE: (650) 416-4836
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

LIC9099 (FAS) - (06/04)

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