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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200806
Report Date: 07/25/2024
Date Signed: 07/25/2024 04:11:43 PM


Document Has Been Signed on 07/25/2024 04:11 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:JAIRUS CABUENAFACILITY TYPE:
740
ADDRESS:633 S KNICKERBOCKER DRTELEPHONE:
(408) 749-8600
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:103CENSUS: 71DATE:
07/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Beena KumarTIME COMPLETED:
04:15 PM
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Licensing Program Analysts (LPAs) Christine Dolores and Santino Fortes arrived unannounced to conduct the facility's required 1 - year annual inspection. LPAs met with Executive Director (ED) Beena Kumar.

During visit, LPAs toured the facility with ED to include the assisted living and memory care units. LPAs and ED also toured the dining rooms, kitchen, common areas, 10 resident bedrooms, bathrooms, activity rooms, and exterior.

All fire exit routes are free and clear of obstruction. Stairwell C contained an evacuation chair. Facility temperature maintained between 71 - 77 degrees Fahrenheit. Fire extinguishers last serviced on 10/05/2023. Carbon monoxide detector present in the facility. Fire places observed screened. Posters observed in the lobby area to include the ombudsman and licensing complaint poster. Activities calendar posted in assisted living and memory care.

Facility has at least 2 days worth of perishables and 7 days worth of non-perishables foods. Refrigerator temperature maintained between 36 - 40 degrees Fahrenheit. Freezer temperature maintained at 0 degrees Fahrenheit. Items inside the refrigerator observed covered. Facility has sufficient cups, plates, bowls, and utensils. Daily menu posted outside of the dining room area.

LPAs and ED entered into rooms 303, 313, 222, 202, 206, 103, 106, 409, 415, and 416. All rooms observed with adequate lighting, a bed, linens, night-stand, and dresser. Showers equipped with grab bars and non-slid floors. Bathroom hot water temperature ranged from 106 - 128 degrees Fahrenheit. Rooms 313, 207, 206, 103, and 106 had light bulbs that were burnt out. Room 313's bathroom fan observed with built-up dust. Room 207's sink faucet observed with very low water pressure. ED immediately placed work orders for the items. SEE LIC809-C.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: SUNRISE OF SUNNYVALE
FACILITY NUMBER: 435200806
VISIT DATE: 07/25/2024
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LPAs reviewed 10 resident files. 10 out of 10 resident files contained a signed admissions agreement, physician's report, TB result, service plan, identification and emergency contact information, consent forms, safeguard personal property and valuables, and personal rights form. LPAs reviewed 5 resident's centrally stored medications and centrally stored medication records. LPAs interviewed 4 residents.

LPAs reviewed 5 staff files. 5 out of 5 staff files reviewed are fingerprint cleared and associated to the facility. Staff files contains a 1st Aid Certification, health screening, and TB result. LPAs reviewed 5 out of 5 staff training records.

Facility has an infection control plan. Facility has an emergency disaster plan. Emergency food supplies and emergency lighting observed. Emergency drills are being conducted quarterly.

The following documents were obtained to include: Change of Administrator documents
(Administrator Certificate, Resume, LIC500, and Photo ID/DL) and liability insurance.

ED will email LPA Dolores the Board Letter once obtained and updated Emergency Disaster Plan.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided.

This report was reviewed with Executive Director, Beena Kumar and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC809 (FAS) - (06/04)
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