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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201317
Report Date: 05/22/2024
Date Signed: 05/22/2024 04:17:38 PM

Document Has Been Signed on 05/22/2024 04:17 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:
05/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Administrator, Ryan Golze and Director of Health Services, Adriana De La OTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Administrator, Ryan Golze and Director of Health Services, Adriana De La O and stated the purpose of today's visit.

During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

LPA Rai randomly toured 10 resident bedrooms. 10 out of 10 resident bedrooms had available bedding, drawers, and functioning lights. The resident bathrooms had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 109.6 degrees F - 113.1 degrees F.

Fire extinguisher was observed and inspected on 3/5/2024. Facility fire system was inspected by third party vendor on 3/11/2024. Facility fire sprinklers were inspected by third party vendor on 3/7/2024. Facility had 1 carbon monoxide detector next to the gas fireplace and the detector was in working condition. The last disaster drill was conducted on 5/6/2024.

LPA Rai will return another day to complete annual inspection. This report was reviewed with Administrator, Ryan Golze and Director of Health Services, Adriana De La O and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
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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