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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201317
Report Date: 03/08/2021
Date Signed: 03/09/2021 09:13:17 AM

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: 110DATE:
03/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Nelson RodriguesTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Case Management tele-visit 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.

The purpose of the tele-visit was as a follow up on the case management conducted on 10/08/20 regarding the death of a resident (R1) on 10/5/20. Death report (LIC624A) received on 10/6/20 stated that R1 was found unresponsive at the facility premises on 10/5/20 at around 2:15pm. 911 was called and R1 was pronounced dead at 2:47pm. The cause of death was unknown at the time of the report. The department conducted staff interviews.

On 10/14/20, the department received a copy of R1's death certificate. Based on records review, the resident's cause of death was complications of a clinically diagnosed neurologic disorder.

No deficiencies cited during today's tele-visit. Report was discussed with and a copy sent to Nelson Rodrigues 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: 03/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021
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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