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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201317
Report Date: 02/20/2024
Date Signed: 02/20/2024 03:27:51 PM


Document Has Been Signed on 02/20/2024 03:27 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:NELSON RODRIGUESFACILITY TYPE:
741
ADDRESS:22445 CUPERTINO ROADTELEPHONE:
(408) 454-5600
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY:190CENSUS: 120DATE:
02/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH: LVN Residential Manager, Fidel ManuelTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an case management visit to address information obtained during the complaint investigation 8/10/2023. LPA Rai met with LVN Residential Manager, Fidel Manuel and stated the purpose of the visit.

During investigation, it was disclosed that the resident (R1) did not have a physician's order to use bed rails. Resident Service Director (RSD) stated he/she was not aware of the regulation and did not have a physician's order on R1's file for using bed rails. RSD confirmed R1 was not receiving hospice services at the time of using the bed rails.

During review of documents obtained during investigation, R1's has a history of falls, but Need and Services Plan did not state how facility will meet R1's fall-risk behavior. Based on review of R1's Appraisal dated 5/10/2023 stated R1 had a 9 episodes of fall in the past year. Based on review of R1's Physician's Report dated 6/17/2022, R1's physician has noted under "Other Conditions" as repeated falls. R1's Service Plan dated 5/10/2023 did mention the history of falls but it did not address R1's needs and how the facility would address this 'Physical/Health" concern.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. This report was reviewed with LVN Residential Manager, Fidel Manuel. A copy of the report and Appeal Rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 02/20/2024 03:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 COMMUNITY
FACILITY NUMBER: 435201317

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/27/2024
Section Cited
CCR
87463(a)

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87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate.

This requirement is not met as evidenced by:
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LVN Residential Manager stated facility will submit a written plan of action on updating resident's appraisals accurately and understanding the regulations by POC due date.
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Based on interview and record review, R1's Service Plan did not address R1's history of falls which did not keep the appraisal accurrate which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
02/27/2024
Section Cited
CCR87608(a)(3)

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87608 Postural Supports (a)(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.

This requirement is not met as evidenced by:
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LVN Residential Manager stated facility will submit a written plan of action on ensuring written order from a physician is maintained in resident's file who require a bed rail and understanding the regulations by POC due date.
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Based on interview and record review, R1 did not have a written order from a physician for the bed rail which was in use which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2