435202780-5-28-2021-26-AS-YNGG-C3FRJH-20210528130358

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202780
Report Date: 05/13/2021
Date Signed: 05/28/2021 01:04:06 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:	SONNET HILL		FACILITY NUMBER:	435202780
ADMINISTRATOR:	HAHKLOTUBBE, DAVID		FACILITY TYPE:	740
ADDRESS:	429 MERIDIAN AVE		TELEPHONE:	(408) 731-0019
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95126
CAPACITY:	80	CENSUS: 0	DATE:	05/13/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	David Hahklotubbe		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Yatfai Eric Ng, Anna Bui, and Ryker Heberle conducted an announced pre-licensing inspection. LPAs met with the representative - Executive Director (ED) David Hahklotubbe. This facility was 3-story building, had a capacity of 80 residents. Fire clearance approved for 80 non-ambulatory. First floor had a dining room for residents. Second floor was for memory care unit and third floor was for assisted living residents. This facility was not licensed before and had no resident currently. LPAs toured the facility inside and outside with ED. A device was installed at the entrance to check temperature of the visitors. A sign-in sheet and COVID-19 questionnaire were present at the reception area. The facility was well lit and in good repair, LPA did not see any damaged window screens, cracked floor, or broken furniture, etc. Facility's living room and dining room were furnished and had functioning light fixtures. LPAs toured the restrooms in all floors, and room 215, 219, 310, and 329. All restrooms had grab bars installed. Residents' bathrooms had nonskid floors. Hot water temperature was measured, out of range of 105 to 120 degrees F. The elevator was functioning in the facility. There were functioning refrigerators in the kitchen. The centrally stored medication rooms in each floor were locked, ready for storage. LPA Ng observed the carbon monoxide/smoke detectors and alarms were functioning. LPA Ng randomly inspected the fire extinguishers in each floor. They were fully charged, last serviced in 10/13/2020. There was no open body of water outside the facility. There was no obstruction in all passageways inside the facility, and there was no obstruction in any of the emergency exits. Egress doors were tested and functioning. At 11:55 AM, Component III orientation was given to ED.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: SONNET HILL	FACILITY NUMBER: 435202780
	VISIT DATE: 05/13/2021

NARRATIVE

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The following issues needed to be fixed before LPAs could recommend licensure:

Hot water temperature had to be between 105 and 120 degrees F.
Evacuation chairs had to be installed in each stairwell.
A complaint poster (PUB 475) should be the size of 20 x 26".

The facility had a valid liability insurance .

Once LPA Ng received the proof of corrections, a recommendation would be submitted to the Centralized Applications Bureau (CAB) and a final review of the application would be conducted. The application was subject to final approval by CAB. Additional requirements might still be required.

This report was reviewed with ED and a copy was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021

LIC809 (FAS) - (06/04)

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