<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201400
Report Date: 02/08/2022
Date Signed: 02/09/2022 08:22:02 AM

Document Has Been Signed on 02/09/2022 08:22 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SUNNY ORCHARD PLACEFACILITY NUMBER:
435201400
ADMINISTRATOR:THERESA CARRFACILITY TYPE:
740
ADDRESS:1155 POME AVENUETELEPHONE:
(408) 737-2474
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 6CENSUS: 6DATE:
02/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:THERESA CARRTIME COMPLETED:
12:05 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) Steve Chang, licensing Program Manager (LPM) Sarah Yip, and Program Clinical Consultant (PCC) Mirabelle Villamin conducted Technical Assistant - PCC through tele-inspection (Zoom),and met with Administrator (ADM) Theresa Carr.

The purpose of this TA PCC Tele visit was to review the facility COVID-19 infection mitigation plan and conducted inspection of the facility to ensure plan is being carried out and to provide support and guidance to staff in mitigating the spread of virus.

During tele-visit inspection, a tour of the facility was conducted which started at the main entrance to check COVID-19 signage and screening procedures. The facility has the COVID-19 posters at the main entrance including screening questionnaire forms, hand sanitizer, face masks, thermometer, glove, and a visitor log book at the screening station.

The facility common areas were inspected such as the kitchen, living room, dinning area, bathrooms were observed. There are 6 resident single bedrooms, two and half bathrooms in facility. Trash cans were observed with covers. Paper towels with holders, and washing hands signs by the sinks were observed. Cloth towels were observed in the restrooms. The resident bedrooms were observed. ADM stated all the residents and staff are fully vaccinated and done with boosters.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2022
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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: SUNNY ORCHARD PLACE
FACILITY NUMBER: 435201400
VISIT DATE: 02/08/2022
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
26
27
28
29
30
31
32
Based on today's inspection, the facility is being recommended the following:

1. Facility to frequently wipe and disinfect high touch areas.
2. Remove the cloth towels in kitchen and restrooms.
3. Monitoring residents and staff for symptoms and change of condition'
4. Do the laundry for negative residents first, then do the laundry for the positive residents.
5. Use high temperature hot water for laundry.
6. N95 Seal check reference:
https://www.cdc.gov/niosh/docs/2018-130/pdfs/2018-130.pdf
https://www.youtube.com/watch?v=oU4stQgCtV8
7. Facility to review PINs (Providers’ Information Notification) through CCLD website: www.ccld.ca.gov.
8. Facility to have more COVID posters in facility.
9. Facility to conduct staff training at least monthly or frequently such as donning and doffing PPE and COVID -19 updates.



No deficiencies cited during today's Tele Visit. Exit interview conducted with Administrator.
A copy of this report emailed to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2