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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201317
Report Date: 09/08/2023
Date Signed: 03/19/2024 11:06:16 AM


Document Has Been Signed on 03/19/2024 11:06 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: 111DATE:
09/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Director of Health Services, Adriana De La OTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit today. LPA Rai met with Director of Health Services (DHS) Adriana De La O and stated purpose of today's visit.

The purpose of the case management visit was to follow up on an incident which occurred on 8/17/2023 at 9:37pm when resident (R1) cut off the wander guard and left the facility unassisted on the electric scooter. Per Incident Report, the facility received a phone call from R1's child stating R1 was out of the facility and approximately 7 miles away from the facility. The incident was reported to the Department via Unusual Incident Report on 8/17/2023.

During today's visit, LPA Rai interviewed DHS and two staff (S1-S2). DHS stated R1's child informed the facility about R1 was out of the facility unassisted and 911 was called. Law enforcement officers were with R1 and DHS met with them before they escorted R1 back to the facility. R1 informed DHS of cutting the wander guard from the scooter before leaving the facility from the front door. Upon arrival back to the facility, DHS and facility staff found the wander guard in R1's room. DHS believes R1 left the facility from the front door when staff were not present at the reception area. Per DHS, the receptionist is at the reception area until 8pm and after 8pm a security guard will take over the reception area.

R1 has left the facility previous to this incident on 10/6/2022 and R1 had cut the wander guard before leaving the facility unassisted. Per DHS, R1 does not have cognitive impairment and R1 does have cognitive abilities to make decisions. Per R1's Resident Appraisal 8/30/2023, R1 needs special observation/night supervision due to confusion, forgetfulness wandering and it stated "Resident has wander guard". Per record review of R1's Physicians Report 8/4/2023, R1 is unable to leave the facility unassisted and R1 uses a motor scooter due to motor impairment.

Continuation on LIC 809-C, Page 1 of 2.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023
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 3


Document Has Been Signed on 03/19/2024 11:06 AM - 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: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2023
Section Cited
CCR
87468.2(a)(4)

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Additional Personal Rights of Residents in Privately Operated Facilities:(a)... residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in...qualifications, and competency to meet
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Director of Health Services will submit a plan of action to ensure resident's safety by POC date. During today's visit, LPA Rai was shown a picture of the facility placed a second wander guard underneath R1's scooter.
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their needs. This requirement was not met as evidenced by: R1 was not provided care and supervision to meet R1's needs wherein R1 left the facility unassisted while facility staff were unaware which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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Director of Health Services agreed and understood.

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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: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


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
VISIT DATE: 09/08/2023
NARRATIVE
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Page 2 of 2.

Based on the interviews, the day of the incident 8/17/2023, the facility staff were not aware resident had left the facility until R1's child informed the facility staff. R1 was being tracked by phone and was showing location approximately 7 miles away. The facility staff last saw R1 during dinner time at 6pm and DHS had last seen R1 at 7pm when R1 was done with dinner and back to the room. At 8pm, S1 went to R1's room to administer medications, R1 was not found in the room and the room lights were off. S1 assumed R1 was with family even though the log did not show R1 was signed out of the facility. 2 of 2 staff stated residents' families will often not sign out residents out of the facility, even though it is a facility policy. At 9:37pm, S2 received the phone call from R1's child, informing R1 was not at the facility and notified S2 that R1 was approximately 7 miles away and was alone and unassisted.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.

LPA Rai spoke with Director of Health Services (DHS) Adriana De La O and Executive Director Randy Herzig and went over report and today's deficiencies and they both agreed and understood.

Exit interview was conducted with Director of Health Services (DHS) Adriana De La O and a copy of this report was provided. Appeal Rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3