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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200806
Report Date: 06/22/2021
Date Signed: 06/30/2021 10:30:45 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: 78DATE:
06/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Tayebeh BagheriTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced infection control site visit today. LPA met with the Executive Director (ED) Tayebeh Bagheri.

One central entry point was designated for all staff, residents, and visitors. A temperature screening station, sign in sheet, and hand sanitizer were present at the entrance. LPA was temperature checked upon entry. LPA toured the facility with ED.

The facility was observed to be in sanitary condition. Hand sanitizers were available throughout the facility. All staff members were observed to be wearing masks. Some residents were having meals in the dining room. Tables in the dining rooms were at least 6 feet apart from each other.

LPA inspected 2 public restrooms. The restrooms observed to be adequately stocked with paper towels, hand soap, and covered trash bin. Hand washing signs were posted.

Facility was observed to have adequate supply of PPE in the storage area. A plan for epidemic outbreak specific to COVID-19 mitigation plan report (LIC 808) was in file.

No deficiency cited during visit. However, an advisory note was issued. See LIC 9102.

This report was reviewed with the ED and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
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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