435202903-9-26-2023-26-AS-SRAI-CW2RQQ-20230926131354

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202903
Report Date: 09/26/2023
Date Signed: 09/26/2023 01:14:02 PM

Document Has Been Signed on 09/26/2023 01:14 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 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: 0	DATE:	09/26/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Administrator Tina Bagheri Tayebeh.		TIME COMPLETED:	01:15 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) Simi Rai arrived announced to conduct the facility's pre-licensing visit. LPA met with Administrator Tina Bagheri Tayebeh. There are no clients present on site. The facility has three floors - floors one, two and three consist of assisted living, and floor one and two consist of memory care. The facility has an approved fire clearance for 114 non ambulatory in which 20 may be bedridden. LPA Rai observed evacuation chairs on the 3rd floor exit door in the stairwell, but none were observed on the 2nd floor. The facility placed temporary sturdy chairs on the 2nd floor while the applicant is ordering evacuation chairs for the 2nd floor. The applicant will submit a picture to LPA Rai once received and placed on each stairwell on the 2nd floor. LPA toured the facility inside and outside including the apartments, bathrooms, kitchen, dinning room, stairwells and common areas. Resident rooms were equipped with proper furniture and lighting. LPA Rai observed the windows in the Memory Care resident rooms and each window was restricted with bars on the side, the window opening up only approximately 3 to 4 inches. Facility temperature maintained at 70 degrees Fahrenheit. Bathrooms are equipped with grab bars, nonskid floors, hygiene supplies, and toiletry. Facility kitchen is equipped with cups, plates, utensils, and cooking supplies. Hot water temperature was measured between 105.8 to 118.8 degrees Fahrenheit in the common bathrooms. Battery operated flashlights observed on-site. LPA observed supplies of perishable and non-perishable supplies. Refrigerator temperature was maintained at 35 degrees Fahrenheit. Freezer temperature was maintained at 0 degrees Fahrenheit. The kitchen does not have resident access and is separate from the dining area. Continuation on LIC 809-C, Page 1 of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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 2

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: SUNRISE OF CUPERTINO	FACILITY NUMBER: 435202903
	VISIT DATE: 09/26/2023

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The following posters observed to include the emergency telephone numbers, personal rights, RCFE compliant poster, complaint information, Rights of Resident Councils, Personal Rights of Residents in All Facilities, required mask, and facility sketch.

The facility has designated medication rooms with locked medication cabinets. LPA observed first aid kit with the following supplies: bandages, scissors, tweezers, and thermometer.

COMP III was reviewed and completed with the Administrator.

No issues noted during this pre-licensing inspection.
LPA observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

This report was reviewed with Administrator Tina Bagheri Tayebeh and a copy of the report was provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2