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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201317
Report Date: 05/28/2021
Date Signed: 05/28/2021 11:08:56 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:
05/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Nelson RodriguesTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Infection Control site visit today. LPA met with Executive Director (ED) Nelson Rodrigues and Director of Health Services (DHS), Adriana De La O.

LPA toured the facility inside and out. Facility was observed to have a designated entry point for universal symptom screening including temperature check and a questionnaire log. Hand sanitizers were available to residents, staff and visitors; and markers were observed to promote social distancing. All staff present were observed wearing masks.

Random bathroom and restroom were observed supplied with hygiene products and hand washing signs were posted. Bedrooms, kitchen, dining room, common/activity rooms, and the exterior of the facility were inspected. All fire exit routes were observed clear of obstructions. Medications are secured and only accessible to staff.

LPA reviewed the facility COVID-19 related infection control policies and procedures with ED and DHS including surveillance testing, disinfecting, staffing, training, isolation, PPE use and inventory.

No deficiencies issued per Title 22 of the California Code of Regulations. LPA reviewed report with and a copy provided to ED Nelson Rodrigues and DHS Adriana De La O.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne RoadillaTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
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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