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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201400
Report Date: 06/28/2022
Date Signed: 06/28/2022 10:34:46 AM


Document Has Been Signed on 06/28/2022 10:34 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:SUNNY ORCHARD PLACEFACILITY NUMBER:
435201400
ADMINISTRATOR:THERESA CARRFACILITY TYPE:
740
ADDRESS:1155 POME AVENUETELEPHONE:
(408) 737-2474
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:6CENSUS: 6DATE:
06/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ofelia Guanzon and Miguela CruzTIME COMPLETED:
10:40 AM
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On 06/28/2022, Licensing Program Analysts (LPAs)Mandeep Kaur and David Marrufo conducted an unannounced infection control site visit today. LPAs met with Administrator Assistant Ofelia Guanzon

A temperature screening station, sign in sheet, and COVID-19 questionnaire were present at the entrance. Hand sanitizing stations were present. LPAs were checked in by the Administrator assistance before the tour. LPAs toured the facility with Administrator assistant

All staff members were observed to be wearing masks.

1 Private bathroom and 1 of the common restrooms observed to be adequately stocked with paper towels and hand soap.

The main kitchen was inspected. There was sufficient perishable food for at least 2 days and nonperishable food for at least one week.

Facility was observed to have adequate supply of PPE in a storage box.

3 of the 6 bedrooms were observed. Outside of the facility was observed.
.
No deficiency cited during visit.

This report was reviewed with Miguela Cruz and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 726-4986
LICENSING EVALUATOR NAME: Mandeep KaurTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022
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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