435200806-6-25-2021-26-AS-SYIP-C4EVUV-20210628164520

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200806
Report Date: 06/22/2021
Date Signed: 06/25/2021 11:30:25 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
07/01/2020 and conducted by Evaluator Yatfai Ng

COMPLAINT CONTROL NUMBER: 26-AS-20200701171423

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:	02:15 PM
MET WITH:	Tayebeh Bagheri		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained an injury while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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.

On 07/10/2020, LPA conducted an initial complaint investigation. LPA interviewed 1 staff and obtained a copy of residents’ roster. On 09/03/2020, LPA interviewed R1 (alleged victim)’s family member (FM). On 10/09/2020, LPA interviewed 4 residents and 1 resident’s private companion. On 10/15/2020, LPA interviewed 5 staff.

Between 07/10/2020 and 10/15/2020, 7 staff were interviewed. 7 out of 7 staff denied they had abused any residents. 7 out of 7 staff denied seeing residents being abused while in care.

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)

Page: 1 of 2

Control Number 26-AS-20200701171423

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 10/09/2020, 4 residents were interviewed. 4 out of 4 residents denied being abused while in care. 4 out of 4 residents denied seeing other residents being abused while in care.

Between 09/03/2020 and 10/09/2020, 1 family member of the resident, and 1 private companion of a resident were interviewed. 1 out of 1 family member of the resident, and 1 out of 1 private companion of a resident stated they did not see any residents being abused while in care.

In an interview, it was revealed that FM asked if R1 was ever abused while in care. R1 replied negative. FM did not see any abuse during FM’s past visits. FM told LPA that FM felt safe to have R1 residing in the facility.

Based on record review, an investigation report from the Sunnyvale Police Department revealed police officers went to the facility to interview all related parties. There was no indication of abuse by the staff of the facility.

Based on interviews and file review, the department has determined that the allegation was UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

This report was reviewed with ED and 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)

Page: 2 of 2