<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201198
Report Date: 09/14/2021
Date Signed: 09/15/2021 10:51:23 AM

Document Has Been Signed on 09/15/2021 10:51 AM - It Cannot Be Edited

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:SUNFLOWER CARE HOMEFACILITY NUMBER:
435201198
ADMINISTRATOR:VICTORIA REGALAFACILITY TYPE:
740
ADDRESS:631 TORRINGTON DRIVETELEPHONE:
(408) 733-6171
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 7CENSUS: 6DATE:
09/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Victoria RegalaTIME COMPLETED:
02:20 PM
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
Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced infection control site visit. LPA met with the Licensee Victoria Regala.

One central entry point was designated for all staff, residents, and visitors. A temperature screening station, questionnaire, and sign in sheet were present at the entrance. LPA was temperature screened before entering.

LPA toured the facility. The facility was observed to be in sanitary condition. There were COVID-19 signs and hand sanitizers at the entrance and in the facility. LPA inspected 1 restroom that was not in use. The restroom was observed to be adequately stocked with paper towels, hand soap, and a covered trash bin. Hand washing sign was present. Hand washing sign was also posted in the kitchen to remind the staff to wash their hands before handling food. There was an adequate supply of personal protective equipment in the storage areas.

A plan for epidemic outbreak specific to COVID-19 mitigation plan report (LIC 808) from the facility was in file. LPA discussed the infection control with Licensee. LPA reviewed the current Provider Information Notice PIN 21-40-ASC with Licensee. All residents and all staff were fully vaccinated and required so according to facility's policy.

No deficiency cited during visit.

This report was reviewed with Licensee. A copy of this report were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2021
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 1