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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201317
Report Date: 05/24/2024
Date Signed: 05/24/2024 05:44:06 PM

Document Has Been Signed on 05/24/2024 05:44 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:SUNNY VIEW RETIREMENT COMMUNITYFACILITY NUMBER:
435201317
ADMINISTRATOR/
DIRECTOR:		RYAN GOLZEFACILITY TYPE:
741
ADDRESS:22445 CUPERTINO ROADTELEPHONE:
(408) 454-5600
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 190CENSUS: 115DATE:
05/24/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Administrator Ryan Golze and Director of Health Services, Adriana De La OTIME VISIT/
INSPECTION COMPLETED:
05:50 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) Simi Rai arrived unannounced to conduct a continuation of the annual inspection from 5/22/2024 and met with Director of Health Services, Adriana De La O and Administrator Ryan Golze.

During today's visit, LPA Rai continued to review 10 resident files and 8 staff files.

LPA Rai reviewed at random resident's Centrally Stored Medication Log and centrally stored medications in the Medroom. LPA Rai reviewed Resident #11's medication #1 the number of tablets in the bottle did not match the Central Stored Medication Record. Medication #1 should have 149 tablets in the bottle, LPA and Director of Health Services, Adriana De La O observed 155 tablets, which meant there were 6 extra tablets in the bottle. LPA Rai re-counted the medication with Staff S1 as well and the medication count in the bottle was 155.

87411 Personnel Requirements - General is being cited during today's visit. LPA Rai would like to clarify the facility personnel being in sufficient in numbers is not the concern, however the facility personnel's actions and documentation observed in Medroom are not competent to provide the services necessary to meet the resident's needs.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. This report was reviewed with Director of Health Services, Adriana De La O and Administrator Ryan Golze. A copy of the report was provided. Appeal Rights were provided.




SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2024
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 2
Document Has Been Signed on 05/24/2024 05:44 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Simranjit Rai On 05/24/2024 at 05:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNNY VIEW RETIREMENT COMMUNITY
FACILITY NUMBER: 435201317

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
05/25/2024
Section Cited

1
2
3
4
5
6
7
87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on record review, interview and observation R11's medication #1 was not administered to R11 which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
Under Appeal
Type A
05/25/2024
Section Cited

1
2
3
4
5
6
7
87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on record review, interview and observation, R11's MARs noted medications administered but 6 addititonal tablets were in medication bottle, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2