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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202621
Report Date: 12/31/2020
Date Signed: 01/04/2021 11:33:01 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:SUNRISE VILLA SAN JOSEFACILITY NUMBER:
435202621
ADMINISTRATOR:ZEPEDA, JESSICAFACILITY TYPE:
740
ADDRESS:4855 SAN FELIPE RDTELEPHONE:
(408) 223-1312
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:140CENSUS: DATE:
12/31/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Jessica ZepedaTIME COMPLETED:
12:00 PM
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LPA Steve Nguyen and CDPH RN Emma Erickson conducted a virtual Technical Assistance at Sunrise Villa Jose with Administrator Jessica Zepeda.

Census: MC=18 AL=75

Virtual tour of facility consisted of inspecting: front/universal entry, Backyard, living room, dinning room, common/shared bathroom, and front of isolation room. All areas of inspection were found to contain components of: proper hygiene (soap & paper towels & hand sanitizers), PPE stations (including wastebins with lid), signage observed for covid mitigation, designated seatings & marking's to ensure proper social distancing.

Medications and cleaning supplies were locked in cabinets. Observed staff and residents wearing masks. Meals are served in room and laundry are separated to mitigate the spread of covid. Facility has plan in place to designate staff to care for covid positive residents. Housekeeping engages in continuous cleaning of facility.

Based upon these observations, the CDPH RN Emma Erickson does not have any recommendations for the facility at this time.

LPA advised Administrator that a copy of this report will be forwarded via email for her to review, sign and return.

END OF REPORT
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: Steve NguyenTELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE:
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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