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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202780
Report Date: 06/02/2022
Date Signed: 06/02/2022 04:57:54 PM

Document Has Been Signed on 06/02/2022 04:57 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SONNET HILLFACILITY NUMBER:
435202780
ADMINISTRATOR:HAHKLOTUBBE, DAVIDFACILITY TYPE:
740
ADDRESS:429 MERIDIAN AVETELEPHONE:
(408) 731-0019
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY: 80CENSUS: 20DATE:
06/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:22 PM
MET WITH:David HahklotubbeTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo arrived at the facility to conduct a complaint investigation and met with Administrator David Hahklottube.

During visit, Administrator Hahklottube stated that the facility had 2 cases of COVID amongst residents and 2 cases of COVID amongs staff. He stated the first COVID case occurred on 05/21/2022 and the next cases occurred on 05/21/2022, 05/21/2022, 05/22/2022, and 05/23/2022. He stated the cases have not been reported in writing to the Department.

A deficiency was cited as per California Code of Regulations, Title 22. See LIC809-D for more information.

This report was reviewed with Administrator Hahklotubbe and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2022
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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Document Has Been Signed on 06/02/2022 04:57 PM - It Cannot Be Edited


Created By: David Marrufo On 06/02/2022 at 04:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SONNET HILL
FACILITY NUMBER: 435202780

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2022
Section Cited
CCR
87211(a)(2)

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Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the
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Licensee agrees to submit an incident report for the four positive COVID cases within 24 hours and submit a statement of understanding regarding reporting requirements, especially pertaining to reporting of epidemic outbreaks, to CCL by POC date.
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welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not met as evidenced by: Licensee did not report 4 COVID positive cases at the facility, which posed a potential safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jackie Jin
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022


LIC809 (FAS) - (06/04)
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