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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202623
Report Date: 12/21/2018
Date Signed: 12/22/2020 04:25:24 PM

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 ASSISTED LIVING OF PALO ALTOFACILITY NUMBER:
435202623
ADMINISTRATOR:GUILHOLT, ELIZABETHFACILITY TYPE:
740
ADDRESS:2701 EL CAMINO REALTELEPHONE:
(703) 273-7500
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:97CENSUS: 89DATE:
12/21/2018
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Amy Saulnier, AdministratorTIME COMPLETED:
01:50 PM
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**This is an amended report to redact confidential names only. No other statements have been amended.**

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Other visit to verify the exclusion of staff, S1. LPA was greeted by Amy Saulnier, Administrator.

LPA obtained a termination record for S1 stating the last day S1 worked was 04/26/2018 and the effective termination date is stated as 05/03/2018.

LPA interviewed staff S2-4 regarding S1's last date of employment at the facility.

Based on evidence obtained during today’s visit, the LPA has verified S1 is not present, employed or residing at the facility. LPA has advised the licensee to disassociate S1 from their roster. LPA obtained an updated LIC 500 during visit. Verification of removal is complete.

No deficiency was cited at this time. This report was reviewed with Amy Saulnier, Administrator, and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2020
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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