435200605-4-23-2021-26-AS-KHOS-C2PLLS-20210504085138

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200605
Report Date: 04/23/2021
Date Signed: 04/23/2021 02:24:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/15/2021 and conducted by Evaluator Steve Nguyen

COMPLAINT CONTROL NUMBER: 26-AS-20210315162858

FACILITY NAME:	ATRIA WILLOW GLEN		FACILITY NUMBER:	435200605
ADMINISTRATOR:	GURSU, UGUR (KURT)		FACILITY TYPE:	740
ADDRESS:	1660 GATON DR		TELEPHONE:	(408) 266-1660
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	63	CENSUS: 43	DATE:	04/23/2021
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Kurt Gursu		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility has an infestation of cockroaches

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Nguyen conducted a tele-visit due to COVID-19 health pandemic to deliver the finding to the above allegation. LPA met with Administrator, Kurt Gursu.

On March 15, 2021, the Department received the above allegation against the facility and conducted an initial complaint investigation tele-visit on March 15, 2021 to inspect facility, observe residents and request facility records.

Based on report from complainant; facility has an infestation of cockroaches. However, there were no corroborating evidence to complainant's claim based on interviews conducted on 3/15/2021 through 3/24/2021. 9 out of 9 staff denied any cockroaches infestation. 5 out of 5 residents denied any cockroaches infestation.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Steve Nguyen	TELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE:

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20210315162858

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ATRIA WILLOW GLEN	FACILITY NUMBER: 435200605
	VISIT DATE: 04/23/2021

NARRATIVE

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On 03/23/2021, LPA conducted an inspection of the facility via FaceTime with Administrator. All areas inspected were well maintained; no signs of pest or droppings of any kind were observed.

Records review from EcoLab Pest Control showed that from 1/11/2020 through 3/11/2021, indicated no pest activity.

This agency has investigated the complaint allegation listed. Based on interviews, review of records, the Department has found that the complaint allegations is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

No Deficiencies cited under California Code of Regulations Title 22.

This report was reviewed with Kurt Gursu, and a copy of this report was emailed to Administrator to sign and return to the Department.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Steve Nguyen	TELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE:

LIC9099 (FAS) - (06/04)

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