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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200806
Report Date: 12/21/2020
Date Signed: 12/22/2020 09:45:48 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: DATE:
12/21/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:03 PM
MET WITH:Tina BagheriTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted a Case Management tele-visit today to deliver an amended report to facility. LPA discussed the report with Executive Director, Tina Bagheri.

A copy of the original and amended reports from a December 7, 2018 Case Management visit was provided to Tina for review and signature.


SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
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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