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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202623
Report Date: 08/13/2021
Date Signed: 08/13/2021 03:05:52 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:TAYEBEH BAGHERIFACILITY TYPE:
740
ADDRESS:2701 EL CAMINO REALTELEPHONE:
(703) 273-7500
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:97CENSUS: 74DATE:
08/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Grace KomasakaTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Grace Komasaka.

During visit, LPA Marrufo toured the facility. LPA Marrufo observed the visitor screening area. LPA Marrufo toured 3 out of 3 hallway bathrooms and found them to have available soap and paper towels. LPA observed facility staff break rooms and observed there to be COVID-19 related posters posted on the walls. LPA observed the facility PPE supply room and observed there to be a 30-day supply of PPEs.

LPA observed the facility dining area and the facility hallways, visitor area, and memory support floor.


No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Grace Komasaka and a copy of the report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
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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