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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200605
Report Date: 09/16/2024
Date Signed: 09/16/2024 11:40:13 AM


Document Has Been Signed on 09/16/2024 11:40 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:ATRIA WILLOW GLENFACILITY NUMBER:
435200605
ADMINISTRATOR:GURSU, UGUR (KURT)FACILITY TYPE:
740
ADDRESS:1660 GATON DRTELEPHONE:
(408) 266-1660
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:63CENSUS: 50DATE:
09/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Administrator Ugur (Kurt) GursuTIME COMPLETED:
11:45 AM
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Licensing Program Analyst Manuel Monter conducted an unannounced case management- Incident visit, regarding an incident report, which reported a resident elopement. LPA with with administrator Ugur (Kurt) Gursu.

On September 12 2024, the Department received an incident report, regarding resident R1. The incident report (IR) stated on September 11, 2024, at 8:30am resident R1 had exited thru the delayed egress in the courtyard. The incident report stated that staff responded to the alarms and began a search. The IR also stated, that while the search was underway, the community received a call at 8:50am, that R1 was on a bus. Staff picked up R1 and returned him/her back to the community.

On September 16, 2024, LPA's interviewed 4 staff, the facility administrator and resident R1.

LPA requested copies of R1's progress notes. LPA also requested a copy of R1's Centrally stored medication record and Medication Administration Log. LPA requested a copy of the delayed egress notification.

LPA determined that the above incident requires further investigation. No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Administrator Ugur (Kurt) Gursu. and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
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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