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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202903
Report Date: 11/08/2024
Date Signed: 11/08/2024 11:15:35 AM

Document Has Been Signed on 11/08/2024 11:15 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: DATE:
11/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Tina BagheriTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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Licensing Program Analysts (LPAs) Christine Dolores and Santino Fortes arrived unannounced to conduct the case management - incident visit. LPA met with Executive Director Tina Bagheri.

The purpose of the visit was to follow-up on a SOC341 the Department received on 11/07/2024 for an incident that occurred on 11/06/2024 regarding alleged sexual abuse.

During visit, 2 staff members were interviewed.

Documents were obtained to include resident (R1)'s physician's report, service plan, face sheet, the detectives case number, staff schedule, staff roster, 3 staff member's job application, and 2 staff member's declaration statement.

This case management will be pending additional investigation.

This report was reviewed with Executive Director, Tina Bagheri and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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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