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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201317
Report Date: 12/01/2022
Date Signed: 12/01/2022 11:14:54 AM


Document Has Been Signed on 12/01/2022 11:14 AM - 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:NELSON RODRIGUESFACILITY TYPE:
741
ADDRESS:22445 CUPERTINO ROADTELEPHONE:
(408) 454-5600
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:190CENSUS: 102DATE:
12/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator, Nelson RodriguesTIME COMPLETED:
11:30 AM
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On 12/1/2022 at 10:15am, Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management visit and met with Administrator Nelson Rodrigues and explained the purpose of the visit was to deliver a letter of exclusion for facility staff S1.

Administrator Nelson Rodrigues signed the Declaration of Service letter stating that the exclusionary letter for S1 was delivered.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Nelson Rodrigues and a copy of the report was provided.

SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022
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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