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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201317
Report Date: 10/08/2020
Date Signed: 10/09/2020 03:58:08 PM

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:SUNNY VIEW RETIREMENT COMMUNITYFACILITY NUMBER:
435201317
ADMINISTRATOR:NELSON RODRIGUESFACILITY TYPE:
741
ADDRESS:22445 CUPERTINO ROADTELEPHONE:
(408) 454-5600
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:190CENSUS: 115DATE:
10/08/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Nelson Rodrigues and Adriana De La OTIME COMPLETED:
02:47 PM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Case Management tele-visit via FaceTime today. The Department has suspended on site visits due to COVID-19 shelter in place order by Governor Newsom. LPA met with Executive Director (ED) Nelson Rodrigues and Director of Health Services (DHS) Adriana De La O.

The purpose of this case management visit is to investigate the death of a resident (R1) at the facility premises on 10/5/20.

At around 2:25pm, LPA conducted interviews with ED, DHS and staff (S1-S2). LPA requested for records regarding R1.

This case management will be kept open pending additional reports.

No deficiencies cited during today's tele-visit. Report was discussed with and a copy sent to Nelson Rodrigues and Adriana De La O to sign and mail back to CCL.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne RoadillaTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020
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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