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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200731
Report Date: 07/03/2020
Date Signed: 08/03/2020 01:24:21 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 SUNNYVALEFACILITY NUMBER:
435200731
ADMINISTRATOR:SILVA, FLAVIOFACILITY TYPE:
740
ADDRESS:175 E REMINGTON DRTELEPHONE:
(408) 738-3410
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:160CENSUS: 108DATE:
07/03/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:14 PM
MET WITH:Layana SantosTIME COMPLETED:
03:21 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced Case Management - Incident tele-visit. Due to current COVID-19 situation, LPA virtually met with Resident Services Director (RSD) Layana Santos.

The purpose of visit today was to conduct a health and safety check, responding to incident report that was sent to the Department on 6/16/2020. The incident report revealed that R1 was sent to hospital on 06/10/2020 due to pain resulted from a previous fall. RSD clarified that the fall happened on 5/28/2020. It was diagnosed with neck fracture that time already. R1 was sent to hospital for pain due to the same diagnosis of neck fracture.

R1's family decided that R1 needed higher level of care. R1 moved out of the facility on 6/23/2020.

Upon reviewing R1's needs and services plan, it was noted R1 received a 1-on-1 24 hours care. RSD stated the facility and staff were aware that R1's condition and behavior. But due to R1's sundown syndrome and impulsive behavior, R1 refused to receive assistance from caregiver and resulted in falling.

No deficiency was cited during visit today.

This report was reviewed with RSD and a copy of this report was emailed to RSD for signature and reference.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2020
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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