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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200806
Report Date: 07/28/2025
Date Signed: 07/28/2025 02:32:27 PM

Document Has Been Signed on 07/28/2025 02:32 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/
DIRECTOR:		GOLIA, ALBERTOFACILITY TYPE:
740
ADDRESS:633 S KNICKERBOCKER DRTELEPHONE:
(408) 749-8600
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 103CENSUS: 81DATE:
07/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Alberto GoliaTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On July 28, 2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. LPA met with the Executive Director (ED), Alberto Golia, and disclosed the purpose of the inspection.

The facility consisted of one building with Assisted Living units on floors one to three, and Memory Care units on the fourth floor. The ED informed the LPA that the facility had 81 residents in care at the time, including 62 in Assisted Living and 19 in memory care.

LPA initiated a walk-through of the facility, accompanied by ED.

LPA inspected the main kitchen and found it clean. The refrigerator, freezer, and pantry cabinets were checked, and there was a sufficient supply of fresh perishable food for two (2) days and nonperishable staples for seven (7) days. No expired food items were found. Open food items were wrapped and dated. The dining rooms in Assisted Living and Memory Care were inspected and were found to be clean, with all furniture in good repair.

LPA inspected randomly selected ten (10) resident rooms in Assisted Living and Memory Care units. The rooms were found to be clean, well-lit, and equipped with the required furniture. LPA inspected the private bathrooms in random rooms. The bathrooms contained soap, grab bars, towels, a trash can, and non-slip flooring. The hot water temperature at the sink faucets measured between 120.6°F and 128.3°F. “No Smoking / Oxygen in Use” signs were observed posted outside the residents’ room where oxygen was administered.

Continued to LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: SUNRISE OF SUNNYVALE
FACILITY NUMBER: 435200806
VISIT DATE: 07/28/2025
NARRATIVE
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LPA inspected the fire extinguishers mounted on the hallway walls in Assisted Living and Memory Care and found them fully charged, with the last service tag dated 11/6/2024. A staff member tested the carbon monoxide detector in the hallway in LPA’s presence, and it was found to be functional. LPA reviewed the Fire Prevention routine inspection report, conducted on 02/04/2025, by the Department of Public Safety Fire Prevention & Hazardous Materials Certified Unified Program Agency, City of Sunnyvale. The last semi-annual Fire Alarm inspection was completed on 04/15/2025 and quarterly Automatic Sprinkler Systems testing was completed on 04/15/2025.

LPA inspected activity areas, theater room, library, lounges, and other commons areas and observed residents actively engaged in recreational programs and activities. All common areas were free from obstructions, and hallways were well-lit.

LPA inspected laundry stations on each floor and observed working washer and dryer units. Sharp objects, detergents, and chemicals were observed to be locked and inaccessible to persons in care. The industrial sized washer and dryer units were observed in the laundry room on the first floor.

LPA toured the outside courtyard and patio areas and found passageways in good condition, free of obstructions, and without any blocking or tripping hazards. These areas had patio tables, chairs, and umbrellas for residents’ use. Delayed Egress was observed on exit doors. No accessible bodies of water or hazards were observed.

LPA observed locked centrally stored medication carts in the Assisted Living and Memory Care units. Medications were organized separately for each resident. Narcotics were locked. All medication bottles and bubble packs were properly labeled. At 11:16 AM, Centrally Stored Medication Records were reviewed, and a medication count check was performed. LPA observed that the medication counts for one (1) medication ‘Hydroxyzine HCL F/C 25 MG tablet’ Evening time bubble pack for one (1) resident (R1) was found to be inaccurate. Two (2) extra days of medication was administered to R1 for ‘Hydroxyzine HCL F/C 25 MG tablet’ medication. The medication from this Evening time bubble pack started on 07/02/2025, R1 was out of the facility from 07/08/2025 to 07/16/2025, and then resumed the medication from 07/17/2025. Today is 12:30 PM on 07/28/2025, a total of 17 days of medication should have been administered to R1, but 19 days of medication bubbles were popped up. The Medication Administration Record did not show records of medication administered prior to 7/14/2025.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: SUNRISE OF SUNNYVALE
FACILITY NUMBER: 435200806
VISIT DATE: 07/28/2025
NARRATIVE
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LPA reviewed six (6) staff personnel records and ten (10) resident records. The LPA observed that 10 of 10 residents had the Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, Consent forms, Safeguard personal property and valuables, and Personal rights forms. LPA observed that 6 of 6 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 6 of 6 staff members were associated with the facility.

LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster Drills were conducted monthly, with the most recent drill completed on 07/13/2025.

The following updated forms are requested to be submitted to CCLD by 08/04/2025:

  • LIC 500: Personnel Report
  • LIC 308: Designation of Facility Responsibility
  • Certificate of Liability Insurance
  • Administrator Certificate(s)

The deficiencies are being cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, and Plans of Correction were reviewed and developed with the Executive Director. A copy of this report and appeal rights were discussed and provided to the Executive Director, Alberto Golia, whose signature on this form confirms receipt of these documents.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/28/2025 02:32 PM - It Cannot Be Edited


Created By: Kiran Jain On 07/28/2025 at 02:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not ensure that 1 of 10 residents (R1) was given the right dosage of ‘Hydroxyzine HCL F/C 25 MG tablet’ medication. The medication from the evening time bubble pack started on 07/02/2025, R1 was out of the facility from 07/08/2025 to 07/16/2025, and then resumed the medication from 07/17/2025. Today is 12:30 PM on 07/28/2025, a total of 17 days of medication should have been administered to R1, but 19 days of medication bubbles were popped up. Two (2) extra days of medication was administered to R1 for ‘Hydroxyzine HCL F/C 25 MG tablet’ medication, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2025
Plan of Correction
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The Executive Director stated that they are bringing the regional director of nursing to assist director of nursing at the facility in auditing every single resident's medication and all the med techs are going to be retrained with a signed training log. The Executive Director will submit the evidence of training log to CCLD by POC due date of 07/29/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Kiran Jain
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2025


LIC809 (FAS) - (06/04)
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