435200605-1-2-2025-26-AS-MMOR-DCJQLK-20250102111604

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200605
Report Date: 01/02/2025
Date Signed: 01/02/2025 11:16:16 AM

Document Has Been Signed on 01/02/2025 11:16 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 GLEN		FACILITY NUMBER:	435200605
ADMINISTRATOR/ DIRECTOR:	GURSU, UGUR (KURT)		FACILITY TYPE:	740
ADDRESS:	1660 GATON DR		TELEPHONE:	(408) 266-1660
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY: 63	TOTAL ENROLLED CHILDREN: 0	CENSUS: 48	DATE:	01/02/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:40 AM
MET WITH:	Administrator Kurt Gursu		TIME VISIT/ INSPECTION COMPLETED:	11:25 AM

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 Analysts (LPAs) Manuel Monter and Simi Rai conducted an unannounced case management visit in regards an incident report, which stated a resident had eloped from the facility. LPAs met with Administrator Kurt Gursu and stated the purpose of the visit. On September 12, 2024, the Department received an Incident Report for September 11, 2024, Resident R1 had exited through a secured delayed egress door in the memory care courtyard at 8:30am. The Incident Report states staff responded to the delayed egress and began a search. While the search was underway, the facility received a call around 8:50am, and was informed R1 was on a bus. R1 was picked up at by staff at 9:05am and returned to the community. On September 13 & 16 and November 7 & 13 and December 19, 2024, LPA Monter interviewed Staff S1- S6. Staff S1 stated the day of the staff was assisting residents with the morning routine. S1 stated he/she was in the restroom when he/she heard the alarm and went to patio delayed egress where the alarm had activated. S1 stated when he/she arrived to the patio delayed egress, the door was closed but the alarm was still ringing. S1 stated he/she imputed the delayed egress code to turn off the alarm. S1 acknowledged that the delayed egress continues to ring when the door has been opened. S1 stated he/she did not immediately look around the area. S1 stated he/she thought R1 had pushed the delayed egress then just gave up and didn’t actually leave the memory care unit. S1 stated he/she then went around the memory care unit looking for R1, because he/she is the only resident who attempts to elope thru the backyard patio door. S1 stated he/she then asked other staff members if they knew where R1 was and that was when S1 stated he/she realized that R1 was not inside the memory care unit. S1 stated the facility conducted a search but couldn’t find R1. S1 stated a good Samaritan contacted the facility and informed the facility R1 had entered the bus and had stopped near the KFC (983 Meridian Ave, San Jose Ca 95126). Page 1 Out of 3.

Romeo Manzano	TELEPHONE: (408) 388-2297
Manuel Monter	TELEPHONE: (408) 324-2112
	DATE: 01/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025

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 4

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: ATRIA WILLOW GLEN	FACILITY NUMBER: 435200605
	VISIT DATE: 01/02/2025

NARRATIVE

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Staff S1-S5 stated R1 has the behavior of wandering and will attempt to elope from the memory care unit at least once a day.

Staff S2 stated he/she was not working on the day of the elopement. Staff S3, the day of the elopement he/she was assisting a resident in room 3 when he/she heard the alarm. Staff S4 stated he/she was working the day of the elopement. S4 stated he/she told S1 to watch R1 and the other residents. S4 stated he/she was helping a resident in bedroom 4. Staff S5 stated he/she was not at the facility on the day of the elopement.

Staff S6 stated the day of the elopement there was 2 care givers on shift and 1 MedTech. S6 stated 1 care giver had an appointment and was not at the facility when the elopement occurred. S6 stated he/she didn’t have an extra care giver for coverage when his/her staff left to go to his/her appointment. S6 stated R1 tries to elope at least 5 times per day and R1 has had this behavior since he/she moved in. S6 stated the delayed egress door needs to be pressed for 15 seconds to open. S6 stated the delayed egress will keep ringing and staff needs to input a code if the door has been opened.

LPA interviewed Facility ADM. ADM stated that morning, R1 had pushed the egress door and eventually opened it. ADM stated a resident from independent living called the facility and informed them that he/she entered the VTA bus with R1, wherein in he/she discovered that R1 could not express where he/she was going, which prompted the call to Atria Willow Glen.

Based on LPA’s observations, the delayed egress alarm in the memory care unit’s patio, the delayed egress needs to be pushed for 15 seconds to open. Once pressed, the delayed egress will activate and sound the alarm. Based on LPA’s testing, the delayed egress can be heard inside the memory care unit. Furthermore, once the delayed egress door has opened, staff needs to input a code to turn off the alarm.

Based on a google maps review, the VTA bus stop, where R1 entered the bus, (Route 64B) is approximately 0.1 miles away from the facility. R1 had travel by transit and was picked up by staff across the street from the KFC on 983 Meridian Ave, San Jose Ca 95126. This is approximately 1.4 miles away from the facility.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: ATRIA WILLOW GLEN	FACILITY NUMBER: 435200605
	VISIT DATE: 01/02/2025

NARRATIVE

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Based on a Review of R1’s Physician’s report, dated August 8, 2024, R1 has a neurocognitive disorder. R1 also has wandering behavior and cannot leave the facility unassisted. Based on a review of R1’s Resident Functional Needs Service Plan, dated September 12, 2024, R1 requires supervision when leaving the community. The form also states R1 demonstrates severe memory loss requiring continuous supervision.

An immediate civil penalty of $500.00 is being assessed against the facility today for violation the absence of supervision, which resulted in R1 eloping from the facility.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.
This report was reviewed with Administrator Kurt Gursu and a copy of the report was provided. Appeal Rights was provided.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 01/02/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 01/02/2025 11:16 AM - It Cannot Be Edited

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: ATRIA WILLOW GLEN	FACILITY NUMBER: 435200605
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87468.1 Personal Rights: (a)(2) Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 01/03/2025
	Plan of Correction
1 2 3 4	Administrator stated he will send a written plan of action on how the facility ensures residents with wandering behaviors will be kept safe.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Romeo Manzano	TELEPHONE: (408) 388-2297
Manuel Monter	TELEPHONE: (408) 324-2112
	DATE: 01/02/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025

LIC809 (FAS) - (06/04)

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