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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200731
Report Date: 06/10/2022
Date Signed: 06/10/2022 03:15:43 PM

Document Has Been Signed on 06/10/2022 03:15 PM - It Cannot Be Edited

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 PERRYMANFACILITY TYPE:
740
ADDRESS:175 E REMINGTON DRTELEPHONE:
(408) 738-3410
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 160CENSUS: DATE:
06/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Byron PerrymanTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mandeep Kaur and David Marrufo conducted an unannounced Case Management visit and met with Administrator Byron Perryman. The purpose of the case management visit was to follow up an an incident report that the facility submitted to the Department on 06/03/2022. The incident report stated that facility staff observed at 8:00 AM on 06/02/2022 that resident R1 was missing from the facility. The incident report states that resident R1 was returned to the facility at 9:00 AM the same day of the incident.

LPA Marrufo spoke with Administrator Byron Perryman on 06/09/2022 and he stated that R1 left the facility prior to a staff being scheduled to operate the front desk at 8:00 AM. He stated R1 is not permitted to leave the facility without assistance.

R1's Appraisal/Needs and Services Plan states that R1 may not leave the building unassisted. R1's Physician's Report at the time of the incident states R1 is not able to leave the facility unassisted.

A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D for more information.

This report was reviewed with Administrator Byron Perryman and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2022
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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Document Has Been Signed on 06/10/2022 03:15 PM - It Cannot Be Edited


Created By: David Marrufo On 06/10/2022 at 02:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ATRIA SUNNYVALE
FACILITY NUMBER: 435200731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/11/2022
Section Cited
CCR
87464(f)(1)

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Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Licensee did not ensure that resident R1, who cannot leave the facility unassisted,
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Licensee agrees to submit a plan to train staff regarding providing care, supervision, and assistance to residents who cannot leave the facility unassisted by POC date. Once training is completed, Licensee agrees to send copies of staff training rosters with dates, signatures, training topic, and name
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was provided the necessary assistance to ensure R1 did not leave the facility unassisted, which poses an immediate risk to the health and safety to the resident in care.
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and qualifications of trainer to CCLD.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jackie Jin
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022


LIC809 (FAS) - (06/04)
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