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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202623
Report Date: 08/29/2022
Date Signed: 08/29/2022 01:47:03 PM


Document Has Been Signed on 08/29/2022 01:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:SUNRISE ASSISTED LIVING OF PALO ALTOFACILITY NUMBER:
435202623
ADMINISTRATOR:GRACE KOMASAKAFACILITY TYPE:
740
ADDRESS:2701 EL CAMINO REALTELEPHONE:
(703) 273-7500
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:97CENSUS: 67DATE:
08/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:43 PM
MET WITH:Grace KomasakaTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Grace Komasaka.

LPA Marrufo toured the inside and outside of the facility. LPA Marrufo observed there to be a a visitor screening area at the entrance. LPA Marrufo observed there to be a PPE supply of at least 30 days, a perishable food supply of at least 3 days and a non-perishable food supply of at least 7 days. LPA Marrufo observed the facility bathrooms to have available soap and paper towels as well as COVID-19 hand washing posters.

LPA Marrufo toured the outside area and found the exits to be cleared of obstructions.

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

This report was reviewed with Administrator Grace Komasaka and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
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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