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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201400
Report Date: 05/16/2024
Date Signed: 05/16/2024 04:00:03 PM

Document Has Been Signed on 05/16/2024 04:00 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:SUNNY ORCHARD PLACEFACILITY NUMBER:
435201400
ADMINISTRATOR/
DIRECTOR:
THERESA CARRFACILITY TYPE:
740
ADDRESS:1155 POME AVENUETELEPHONE:
(408) 737-2474
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 6CENSUS: 6DATE:
05/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with staff S1, Victoria Regala, Administrative Designee. During the visit, LPA observed 6 residents and 2 staff.

LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 3 restrooms and 6 residents bedrooms. The front yard and backyard were inspected. There was no obstruction to block the walkways.

While touring the garage, LPA observed two rooms inside the garage. LPA asked S1 if LPA could enter. S1 stated the staff inside, S2, was "napping". Inside the first room in the garage, LPA observed a black couch with a pillow and blanket. LPA observed S2's medication bottles on the dresser counter as well. S1 stated S2 naps in there because he/she is the night shift staff. LPA also inspected the other room in the garage, which Staff S3 was using, had a bed with pillows and a blanket. (Photographs were taken.) LPA interviewed Staff S2 and S3. Both staff interviewed stated they sleep in the garage and work the night shift from 10pm-7am.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degrees F, and hot water temperature was measured at 116 degrees F in both resident bathrooms.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: SUNNY ORCHARD PLACE
FACILITY NUMBER: 435201400
VISIT DATE: 05/16/2024
NARRATIVE
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Fire extinguisher was serviced in April 30, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on May 2024. LPA requested to review the drill conducted in 2023. S1 stated that information is in the Los Altos care home and the facility ADM would return by tomorrow.

LPA reviewed facility records for 3 residents. While reviewing residents R1 and R2's file, LPA discovered both had empty pre-admission appraisal forms. LPA asked S1 if they had completed them. S1 stated they did not have the forms filled out for R1 and R2 pre-admission appraisal. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 2 residents.

LPA reviewed 3 staff files. LPA requested to review staff training records. S1 stated the training records were in the Los Altos facility. S1 stated the training had been completed, but the records were not available.

By the end of the visit, S1 was unable to provide copies of staff training or documents stating disaster drills had been conducted in 2023.

Deficiencies are being cited during today's visit. This report was reviewed with staff S1, Victoria Regala and a copy of the signed report was provided. Appeal rights were provided.

PAGE 2 OUT OF 2

END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/16/2024 04:19 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/16/2024 04:15 PM


Created By: Manuel Monter On 05/16/2024 at 03:36 PM
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNNY ORCHARD PLACE

FACILITY NUMBER: 435201400

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 05/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview and observation, the licensee did not comply with the section cited above. Staff S1, S2 and S3 acknowledged that staff S2 and S3 sleep in the garage. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
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ADM stated she will send a hand written letter plan of action on how she will ensure she is following her fire clearance. ADM stated he/she will send plan of action regarding staff sleeping in the garage. ADM stated he will send his/her written plan of action by POC date, May 23, 2024.
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. LPA requested to review staff training records. S1 stated the staff training records are not available and could not be found. S1 stated the training has been completed, but she cannot produce them. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
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ADM stated she will send a hand written letter of understanding regarding the regulation. ADM stated she will send the POC letter by poc date, May 23, 2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/16/2024 04:18 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/16/2024 04:16 PM


Created By: Manuel Monter On 05/16/2024 at 03:36 PM
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNNY ORCHARD PLACE

FACILITY NUMBER: 435201400

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 05/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above. Residents R1 and R2 did not have a Pre-admission Appraisal in file. S1 stated the forms have not been filled out. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
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ADM stated she will send a hand written letter of understanding regarding the regulation. ADM stated she will send the POC letter by poc date, May 23, 2024.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. LPA requested to review the drills conducted in 2023. S1 stated those drills were conducted, but could not produce the documentation during visit. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
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ADM stated she will send a hand written letter of understanding regarding the regulation. ADM stated she will send the POC letter by poc date, May 23, 2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
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