435202780-7-9-2025-26-AS-CCHG-DJEVSL-20250709164140

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202780
Report Date: 07/09/2025
Date Signed: 07/09/2025 04:41:54 PM

Document Has Been Signed on 07/09/2025 04:41 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:	SONNET HILL		FACILITY NUMBER:	435202780
ADMINISTRATOR/ DIRECTOR:	LATU, JASMINE		FACILITY TYPE:	740
ADDRESS:	429 MERIDIAN AVE		TELEPHONE:	(408) 731-0019
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95126
CAPACITY: 80		CENSUS: 47	DATE:	07/09/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Jasmine Latu		TIME VISIT/ INSPECTION COMPLETED:	12:31 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 Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Administrator (ADM) Jasmine Latu. On 7/8/2025, the Department received a death report regarding a resident R1. On 7/9/2025, LPA interviewed ADM. ADM stated resident R1 moved in the facility memory care unit room #206 on 5/16/2025. ADM stated R1 is not on hospice care. ADM stated R1 lives in a single room and without 1:1 private caregiver. ADM stated on 7/3/2025 early morning around 3:24AM, NOC shift caregiver S1 and Memory care Director (S2) were in command station area in memory care unit. ADM stated S1 and S2 heard a big bang. S1 and S2 searched for the source of the big noise, and found R1 was on the floor near the kitchenette in R1's room. ADM stated S1 and S2 called 911 immediately, and R1 was sent to hospital. ADM stated S1 and S2 notified R1's family. ADM stated on 7/6/2025, the facility received a notice from R1's family that R1 died around 7:45AM on 7/6/2025, Sunday, in hospital. FM stated R1's cause of death is internal brain breeding. ADM stated R1 has the disease specified in the physician report dated 4/30/2025. ADM stated on 7/5/2025, R1's family (FM) told him/her the hospital doctor told FM that R1 needs surgery for the internal brain bleeding, but R1 was too weak to go through the surgery. The hospital doctor stated R1 cannot survive more than 24 hours if R1 does not receive the surgery for internal brain bleeding. LPA requested R1's physician report, appraisal needs and service, unusual incident report, and internal incident report. Continue on LIC809-C. Page 1 of 2.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Chihhsien Chang
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025

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

LIC809 (FAS) - (06/04)

Page: 1 of 3

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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: SONNET HILL	FACILITY NUMBER: 435202780
	VISIT DATE: 07/09/2025

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
26
27
28
29
30
31
32

LPA interviewed staff NOC shift caregiver S1 and Memory care Director S2. Both stated on 7/3/2025, around 3:24AM, they were in the memory care unit and heard a big bang. They went to resident R1's room and found R1 was on the floor near the kitchenette in R1's room. S1 stated he/she observed R1 had bleeding on the right arn but did not see bleeding on R1's head. S1 called 911 immediately and S2 prepared R1's red folder. R1 was sent to hospital. S1 called R1's family and left message, and notified the facility nurse and ADM. Both S1 and S2 stated this is R1's first fall incident.

ADM stated the facility sent R1's incident report to CCL office on 7/3/2025 and R1's death report to CCL office on 7/8/2025.

This case needs further investigation.

Exit interview was conducted with ADM. The report was provided to ADM for review and signature. A copy of the report was provided to ADM.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Chihhsien Chang
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3