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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200806
Report Date: 07/26/2022
Date Signed: 07/26/2022 02:39:20 PM


Document Has Been Signed on 07/26/2022 02:39 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 OF SUNNYVALEFACILITY NUMBER:
435200806
ADMINISTRATOR:BAGHERI, TAYEBEHFACILITY TYPE:
740
ADDRESS:633 S KNICKERBOCKER DRTELEPHONE:
(408) 749-8600
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:103CENSUS: 77DATE:
07/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:JAIRUS CABUENATIME COMPLETED:
02:50 PM
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On 07/26/2022, Licensing Program Analyst (LPA)Mandeep Kaur and Licensing Program Manager (LPM) Sarah Yip conducted an unannounced Required - 1 Year Annual Inspection. LPA and LPM met with the Executive Director (ED) Jairus Cabuena.

A temperature screening station, sign in sheet, and COVID-19 questionnaire were present at the entrance. Hand sanitizing stations were present. LPA and LPM were checked in by the receptionist before the tour. LPA and LPM toured the facility with ED.
All staff members were observed to be wearing masks.

Several Rooms were observed clean and in good repair in the facility. One of the rooms were observed to be in need of Oxygen sign that facility posted during the visit.

One of the common restrooms was observed to be adequately stocked with paper towels and hand soap.

The main kitchen was inspected. There was sufficient perishable food for at least 2 days and nonperishable food for at least one week.
Facility was observed to have adequate supply of PPE in the multiple storage areas.

The facility's Memory Care area was toured. 1 of the common restrooms observed to be adequately stocked with paper towels and hand soap within the memory care unit as well. LPA recommended to have the close lid trash cans in the common restrooms.
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No deficiency cited during visit.
This report was reviewed with ED and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Mandeep KaurTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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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