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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202903
Report Date: 05/20/2025
Date Signed: 05/20/2025 10:22:00 AM

Document Has Been Signed on 05/20/2025 10:22 AM - 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/
DIRECTOR:		TAYEBEH, TINA BAGHERIFACILITY TYPE:
740
ADDRESS:581 E FREMONT AVETELEPHONE:
(408) 962-2982
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 134CENSUS: 82DATE:
05/20/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Tina BagheriTIME VISIT/
INSPECTION COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – incident visit. LPA met with Executive Director, Tina Bagheri.

This visit is a follow-up on a case management visit conducted on 11/08/2024 regarding sexual abuse by staff (S1) to resident (R1) the night of 11/06/2024. On 11/07/2024, the incident was reported to the Department.

During the investigation, it was found that S1 had inappropriately touched R1’s private areas without consent. The incident was witnessed by a staff member who entered the memory care unit and observed the incident. This staff member immediately rushed to grab another staff and returned to the memory care unit where R1 motioned for the two staff to come over. Due to R1’s diagnosis, R1 primarily relied on physical gesture to communicate. R1 was motioning a grabbing motion in R1’s private areas indicating that R1 was inappropriately touched by S1.

Law enforcement investigated the case and interviewed R1 who was able to articulate that an incident had occurred based on expression. R1 answered yes to the questions of S1 touching R1’s private areas, if he/she was scared, if he/she requested help, if S1 hit him/her, if S1 took his/her pants off, and if R1 saw S1’s private part. R1 was noticeablely distraught during the interview.

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NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2025
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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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)
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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: 05/20/2025
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R1 had a surveillance camera inside his/her room that was set up by R1’s power of attorney (POA). The surveillance camera from R1’s room showed unusual behavior from S1 the night of the incident. Although R1 and S1 were off camera for part of the surveillance footage clips, R1 could be heard yelling for help.

The surveillance footage corroborated with the two staff member/witness statements, when they explained that R1 tried to hand signal being inappropriately touched by S1.

On 11/07/2024, S1 was immediately terminated from the facility.

On 11/12/2024, S1 was immediately excluded from the Department. A case management visit was conducted at the facility and hand delivered S1’s order for immediate exclusion.

On 11/14/2024, S1 was arrested and transported to jail without incident, where S1 remains without bail.

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

This report was reviewed with Executive Director, Tina Bagheri and a copy of the report and appeal rights were provided.

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NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/20/2025 10:22 AM - It Cannot Be Edited


Created By: Christine Kabariti On 05/20/2025 at 10:04 AM
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: SUNRISE OF CUPERTINO
FACILITY NUMBER: 435202903

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/21/2025
Section Cited
HSC
1569.58

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(a) The department may prohibit any person … from employing, or continuing the employment of, or allowing in a licensed facility, or allowing contact with clients of a licensed facility by, any employee, prospective employee, or person who is not a client who has: (2) Engaged in conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California. This requirement is not met as evidenced by:
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On 11/07/2024, S1 was immediately terminated from the facility. On 11/12/2024, S1 was immediately excluded from the Department (Case management completed). Licensee cleared the deficiency prior to visit.
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Based on interview, record review, and observation the licensee did not comply with the section cited above wherein staff (S1) had sexually abused resident (R1) in care which poses an immediate health, safety, and personal rights risk to persons 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.
Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:
Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2025


LIC809 (FAS) - (06/04)
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