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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202903
Report Date: 09/13/2024
Date Signed: 09/13/2024 04:14:07 PM


Document Has Been Signed on 09/13/2024 04:14 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 CUPERTINOFACILITY NUMBER:
435202903
ADMINISTRATOR:TAYEBEH, TINA BAGHERIFACILITY TYPE:
740
ADDRESS:581 E FREMONT AVETELEPHONE:
(408) 962-2982
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:134CENSUS: 77DATE:
09/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Assisted Living Coordinator Lucely Tan
Maintenance Coordinator Gerardo Vallejo
TIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPAs) Simi Rai and Marcela Yanez conducted an unannounced Required 1 Year visit. LPAs met with Assisted Living Coordinator Lucely Tan and Maintenance Coordinator Gerardo Vallejo and stated the purpose of today's visit.

During visit, LPAs toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPAs toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. LPAs observed additional food supply areas and secured areas for cleaning supplies and laundry detergents.

LPAs toured the resident bedrooms. Ten out of ten resident bedrooms had available bedding, drawers, and functioning lights. The resident bathrooms had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sink ranged from 111.2 - 117.5 degrees F. The temperature of refrigerator was measured at 39 degrees F and temperature of freezer was measured at -11 degrees F.

LPAs toured the memory care unit on two floors. LPAs inspected all 6 delayed egress exit doors and alarms were functioning and in good repair. The windows in the memory care resident rooms had screens were clean and maintained in good repair and had window guards.

Fire extinguishers was observed and inspected on 08/16/2024. The smoke detectors, carbon monoxide detectors and sprinklers were inspected by third party vendor 06/19/2024. The last fire drills was on 06/20/2024 and 08/28/2024.

LPAs reviewed facility records for ten staff.

LPAs will return another day to complete annual inspection. This report was reviewed with Assisted Living Coordinator Lucely Tan and Maintenance Coordinator Gerardo Vallejo and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Marcela YanezTELEPHONE: (279) 789-1062
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024
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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