435201317-1-13-2022-26-AS-CCHG-CAN368-20220113165753

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435201317
Report Date: 01/12/2022
Date Signed: 01/13/2022 04:58:41 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 COMMUNITY		FACILITY NUMBER:	435201317
ADMINISTRATOR:	NELSON RODRIGUES		FACILITY TYPE:	741
ADDRESS:	22445 CUPERTINO ROAD		TELEPHONE:	(408) 454-5600
CITY:	CUPERTINO	STATE: CA	ZIP CODE:	95014
CAPACITY:	190	CENSUS: 115	DATE:	01/12/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	NELSON RODRIGUES		TIME COMPLETED:	10:30 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) Steve Chang, licensing Program Manager (LPM) Romeo Manzano, and Program Clinical Consultant (PCC) Cristina Wong conducted Technical Assistant - PCC through tele-inspection (Zoom). Met with Administrator (ADM) Nelson Rodrigues and staff Adriana Delao. The purpose of this TA PCC Tele visit is to review the facility COVID-19 infection mitigation plan and conducted inspection of the facility to ensure plan is being carried out and to provide support and guidance to staff in mitigating the spread of virus. During tele-visit inspection, a tour of the facility was conducted which started at the main entrance to check COVID-19 signage and screening procedures. The facility has the COVID-19 posters at the main entrance including screening questionnaire forms, hand sanitizer, face masks, thermometer, glove, and a visitor log book at the screening station. ADM stated the facility already stopped the dining and activities. ADM stated the meals are delivered to resident rooms for residents. LPA toured the public area with ADM including the dinning room, activity room and public restrooms. Dining room and activity rooms were observed closed and the tables in dining room and activity rooms were observed kept social distance. During inspection, it was observed that some of the facility trash bins did not have covers. It was recommended to have facility purchased trash bins with covers or foot pedal. The facility kitchen, laundry room and memory care unit including residents' isolation areas were observed and inspected. During visit, donning and doffing of PPEs was demonstrated by a care staff. PCC suggested that staff must ensure that the use of N95 is securely worn without leaks.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022

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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNNY VIEW RETIREMENT COMMUNITY	FACILITY NUMBER: 435201317
	VISIT DATE: 01/12/2022

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Based on today's inspection, the facility is being recommended the following:

1. Facility to wipe and disinfect high touch areas as frequently.

2. Facility to replace trash bins with covers or with foot pedal bins.

3. Facility to ensure that residents' soiled clothing/linens are separated between the positive and negative residents. For drying clothes, it should be in high heat temperature.

4. Facility to conduct staff training regarding COVID infection and mitigation control. Staff training should be documented.

No deficiencies cited during today's Tele Visit. Exit interview conducted with Administrator.
A copy of this report emailed to the facility for signature.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022

LIC809 (FAS) - (06/04)

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