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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200806
Report Date: 01/26/2021
Date Signed: 02/01/2021 12:04:53 PM

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: 81DATE:
01/26/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Tayebeh Tina BagheriTIME COMPLETED:
01:29 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced tele-case management - incident. Due to COVID-19 pandemic, LPA virtually met with the Executive Director (ED) Tayebeh Tina Bagheri.

The purpose of visit today was to conduct a health and safety check, responding to an unusual incident report (LIC 624) that was sent to the Department on 12/29/2020. The LIC 624 was regarding a resident (R1) wandered off the facility unassisted and sustained injury. R1's physician's report (LIC 602A) dated on 6/30/2020 revealed that R1 was unable to leave the facility unassisted.

Deficiency was cited during visit today.

This report was emailed to ED to review and to obtain signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/02/2021
Section Cited

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87464 Basic Services. (f) Basic services shall at a minimum include: (1)(c)... the facility assumes responsibility for, or provides or promises to provide... ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered...
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This requirement was not met as evidenced by:
Based on record review, R1's physician's report shows R1 is unable to leave facility unassisted. R1 was found outside unassisted and sustained injury.
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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 YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2021
LIC809 (FAS) - (06/04)
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