435200731-12-10-2024-26-AS-KHOS-DC2LEC-20241217074120

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200731
Report Date: 12/10/2024
Date Signed: 12/10/2024 12:15:46 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
09/11/2023 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230911114451

FACILITY NAME:	ATRIA SUNNYVALE		FACILITY NUMBER:	435200731
ADMINISTRATOR:	FLAVIO SILVA		FACILITY TYPE:	740
ADDRESS:	175 E REMINGTON DR		TELEPHONE:	(408) 738-3410
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	160	CENSUS: 105	DATE:	12/10/2024
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Executive Director, Flavio Silva		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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-Staff are not returning authorized representative's calls
-Staff did not seek timely medical care for resident

INVESTIGATION FINDINGS:

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On December 10, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings of the complaint investigation. LPA met with Executive Director, Flavio Silva and explained the purpose of today's visit.

Regarding to the allegation of- staff are not returning authorized representative's call, the reporting party stated that the responsible party called the facility to ask questions and the facility was not returning calls.

Based on interviews, facility staff stated that they have contacted and left messages for the reporting party after an incident that happened to resident #1 (R1).

Based on documentation provided by the facility, it indicated that the facility called, texted and emailed R1's responsible party.

After the investigation, this allegation is deemed to be unsubstantiated. (continue 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cowan April	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

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-20230911114451

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 SUNNYVALE	FACILITY NUMBER: 435200731
	VISIT DATE: 12/10/2024

NARRATIVE

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Regarding to the allegation of - staff did not seek timely medical care for resident, the reporting party stated that the responsible party wanted to know why it took so long to do Cardio Pulmonary Resuscitation (CPR) on R1 and delayed in reviving R1.

According to staff #1 (S1), he/she was called by Staff #2(S2) to the dining room because S2 observed R1 was not well. When S1 arrived in the dining room, S1 also noticed that R1 had a change in health condition and proceeded with calling 911 and while speaking to the 911 operator, S1 observed that R1 was no longer breathing, therefore, S1 started performing CRP as instructed by the 911 operator.

LPA interviewed the reporting party who stated that they were told by the hospital that there was a delay in transferring R1 to the hospital but there was no documentation from the hospital indicating that as well as the facility delayed with performing CPR.

LPA interviewed the administrator who stated that S1 performed CPR immediate after it was instructed by the 911 operator.

After the investigation, this allegation is deemed to be unsubstantiated as there is no proof that there is a delay with staff performing CPR.

Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

This report is reviewed and discussed with Executive Director and a copy is provided.

SUPERVISOR'S NAME: Cowan April	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC9099 (FAS) - (06/04)

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