435202903-1-2-2025-26-AS-KHOS-DD4NFA-20250120092512

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202903
Report Date: 01/02/2025
Date Signed: 01/02/2025 10:08:57 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/24/2024 and conducted by Evaluator Kiran Jain

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20241224094612

FACILITY NAME:	SUNRISE OF CUPERTINO		FACILITY NUMBER:	435202903
ADMINISTRATOR:	TAYEBEH, TINA BAGHERI		FACILITY TYPE:	740
ADDRESS:	581 E FREMONT AVE		TELEPHONE:	(408) 962-2982
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	134	CENSUS: 78	DATE:	01/02/2025
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Tina Bagheri, Executive Director		TIME COMPLETED:	10:20 AM

ALLEGATION(S):

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Facility lack of supervision resident left the facility unassisted.

INVESTIGATION FINDINGS:

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On 01/02/2025, at 8:45 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a complaint investigation visit. LPA met with Executive Director (ED), Tina Bagheri, and disclosed the purpose of the visit.

Regarding the allegation “Facility lack of supervision resident left the facility unassisted”, Reporting Party (RP) stated “ The resident R1 is Bruce Newborn was found at a gas station near the facility by a staff member who was getting gas for their vehicle. R1 is not supposed to leave the facility alone and has wandering behavior. R1 has Mild Cognetive Behavior. The Physicians report states resident is not to leave facility alone. Staff saw resident buying chewing tabacco and then reported it to the facility and took resident back to facility.”

Continued on LIC9099-C

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025

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

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20241224094612

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SUNRISE OF CUPERTINO	FACILITY NUMBER: 435202903
	VISIT DATE: 01/02/2025

NARRATIVE

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Based on the records review conducted on 01/02/2025, LPA reviewed the resident’s roster and didn’t see resident (R1) living at the facility as R1's name was not listed on the resident roster. LPA checked both Assisted Living and Memory care resident’s rosters.

Based on the staff (ED) interview conducted on 01/02/2025, ED stated that the facility doesn’t know the Resident (R1) and they have never lived at the facility. ED stated that they never had any AWOL incidents since the facility opened in October 2023. ED stated they always check Assisted Living Resident’s Physicians report to make sure if the residents can leave the facility on their own or not. Facility’s care managers and front desk have this information to monitor.

Based on observations, interview conducted with the Executive Director, and records reviewed, the department has determined that the allegation is false, could not have happened, and/or is without a reasonable basis. Therefore, the allegation is UNFOUNDED.

No deficiencies were cited under the California Code of Regulations, Title 22.

An exit interview was conducted. A copy of this report was discussed and left with the Executive Director, Tina Bagheri, whose signature on this form confirms receipt of this report.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025

LIC9099 (FAS) - (06/04)

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