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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200731
Report Date: 01/08/2021
Date Signed: 02/01/2021 11:54:06 AM

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:BYRON PERRYMENFACILITY TYPE:
740
ADDRESS:175 E REMINGTON DRTELEPHONE:
(408) 738-3410
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:160CENSUS: 91DATE:
01/08/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Byron PerrymanTIME COMPLETED:
03:08 PM
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Due to COVID-19 pandemic, Licensing Program Analyst (LPA) Yatfai Eric Ng partnered with a Health Facilities Evaluator Nurse (HFEN) Veronica Nazareth from the California Department of Public Health, conducted a Case Management - Other - tele-visit via FaceTime, to provide a technical assistance to prevent and mitigate the spread of COVID-19 at the facility. LPA and HFEN met with the Administrator (ADM) Byron Perryman.

LPA and HFEN toured virtually with ADM holding the telephone showing around the facility. The tour started at the outside of the entrance. There were signs reminding visitors to practice social distance and Provider Information Notices from the Department to explain the visitation limitation. Only 1 entry and exit point for the facility. A screening station with thermometer, gloves, face masks, sign in sheet were observed. LPA, HFEN toured assisted living unit, memory care unit, patio, and staff's break room. Hand sanitizing stations were scattered in the facility. Staff in the facility wore gloves, masks, and goggles/face shields. Restrooms had soap and paper towels readily available. Covered trash bins were available throughout the facility.

The following infection control practices were suggested to prevent, contain, and mitigate the spread of COVID-19:
  1. Chairs should be at least 6 feet apart
  2. Tape chairs or parts of benches that are not to be seated to practice social distancing
  3. Staff should not turn off the faucet without using a piece of paper towel
  4. Staff are to be screened twice a day

ADM stated the recommendations would be implemented. No deficiency cited during visit.

This report was emailed to the ADM to review and to obtain a signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2021
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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