435200806-6-25-2021-26-AS-SYIP-C4EVZM-20210628165258

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200806
Report Date: 06/22/2021
Date Signed: 06/25/2021 11:02:04 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/03/2020 and conducted by Evaluator Yatfai Ng

COMPLAINT CONTROL NUMBER: 26-AS-20201103113407

FACILITY NAME:	SUNRISE OF SUNNYVALE		FACILITY NUMBER:	435200806
ADMINISTRATOR:	BAGHERI, TAYEBEH		FACILITY TYPE:	740
ADDRESS:	633 S KNICKERBOCKER DR		TELEPHONE:	(408) 749-8600
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	103	CENSUS: 78	DATE:	06/22/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Tayebeh Bagheri		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Staff have limited visitation by family member with the resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced subsequent complaint investigation visit today to deliver the complaint investigation finding. LPA met with the Executive Director (ED) Tayebeh Bagheri.

An initial unannounced tele-investigation was conducted by LPA on 11/13/2020. LPA interviewed 1 staff.

On 11/17/2020, LPA interviewed 1 additional staff.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20201103113407

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 06/22/2021

NARRATIVE

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Between 11/13/2020 and 11/17/2020, 2 out of 2 staff stated the facility does not limit any resident’s visitation unless there is a court order for such limitation. Staff disclosed that currently facility has one resident (R1) who has a court order. Both staff stated they are following the court order on obtaining advance authorization for R1’s outings with that named family member on the court document. Both staff denied limiting R1’s visit or required R1’s visit to be supervised.

The review of the court documents on Conservatorship of R1 revealed that R1’s family member shall have reasonable access to visiting R1 in homes and outings with advance notice of planned visits and outings and shall obtain advance authorization from (conservators) regarding outings.”

Based on the Department's interviews and records review, the Department found that the above allegation is UNSUBSTANTIATED. Unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

This report was reviewed with ED. A copy of this report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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