435202621-7-29-2021-26-AS-KHOS-C68N7F-20210825101240

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202621
Report Date: 07/28/2021
Date Signed: 07/29/2021 12:19:14 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/29/2021 and conducted by Evaluator Anna Bui

COMPLAINT CONTROL NUMBER: 26-AS-20210429104450

FACILITY NAME:	SUNRISE VILLA SAN JOSE		FACILITY NUMBER:	435202621
ADMINISTRATOR:	ZEPEDA, JESSICA		FACILITY TYPE:	740
ADDRESS:	4855 SAN FELIPE RD		TELEPHONE:	(408) 223-1312
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	140	CENSUS: 85	DATE:	07/28/2021
		UNANNOUNCED	TIME BEGAN:	01:13 PM
MET WITH:	Jessica Zepeda		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Staff did not address a resident's change in level of care.

INVESTIGATION FINDINGS:

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On 07/28/2021 at 1:13 pm, Licensing Program Analyst (LPA) Anna Bui conducted an unannounced complaint investigation visit to deliver the finding to the above allegation. LPA met with Jessica Zepeda, Executive Director (ED).

Between 05/07/2021 – 07/08/2021, the Executive Director (ED) and 6 staff were interviewed. 7 out of 7 stated when there is a change in condition, the resident gets reassessed to see if their needs can be met at the facility. 3 out of 7 stated if a resident’s needs can be met at the facility, their needs and services plans are updated; however, if the needs of the residents cannot be met, they will get referred out to a facility that can meet their needs. 4 out of 7 stated the reassessment is done by their Assisted Living Supervisor or Resident Care Director. Per ED and 2 staff, 2 residents had a change in their level of care, and a reassessment and update to the resident’s care plan were completed immediately.
-Continued, see LIC 9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20210429104450

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 JOSE	FACILITY NUMBER: 435202621
	VISIT DATE: 07/28/2021

NARRATIVE

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Between 07/01/2021 – 07/08/2021, 5 residents were interviewed. 5 out of 5 stated they have not had a change in condition or a change in their health. 5 out of 5 residents stated staff are always there to assist them when they need help.

On 07/08/2021, ED was interviewed regarding the alleged victim (R6). ED stated R6 did not have a reassessment and there were no updates to R6’s level of care, as R6 did not have a change in condition. ED stated R6 did not show new behaviors, but it was difficult to calm R6 down. ED stated R6 had to be sent to the hospital and did not return, so a reassessment was not needed, as R6 moved out of the facility after that.

7 resident records were also reviewed. 3 out of 7 residents records showed they had a change in their level of care, and all 3 had an initial Physician’s Report, initial needs and services plan, and updated needs and services plan in their file. 4 out of 7 residents did not have a change in their level of care, so there were no updated needs and services plan. A review of the alleged victim’s (R6) records showed that R6 did not have a change in level of care.

The Department has investigated the above allegation. Based on interviews conducted and documents reviewed, the Department found the above allegation to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

No deficiencies were cited during today’s visit.

Exit interview was conducted with Jessica Zepeda, Executive Director. This report was reviewed with Jessica Zepeda, Executive Director, and a copy was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC9099 (FAS) - (06/04)

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