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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200731
Report Date: 04/02/2025
Date Signed: 04/02/2025 12:34:22 PM

Document Has Been Signed on 04/02/2025 12:34 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ATRIA SUNNYVALEFACILITY NUMBER:
435200731
ADMINISTRATOR/
DIRECTOR:		FLAVIO SILVAFACILITY TYPE:
740
ADDRESS:175 E REMINGTON DRTELEPHONE:
(408) 738-3410
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 160TOTAL ENROLLED CHILDREN: 0CENSUS: 88DATE:
04/02/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Flavio Silva, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On April 02, 2025, at 10:30 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident visit regarding a death report for Resident (R1) that was received by the department on March 25, 2025. Upon arrival, the LPA was greeted by the Executive Director (ED), Flavio Silva. The LPA disclosed the purpose of the visit. The ED informed the LPA that the total facility census was 88.

According to R1’s Death Report, R1 had a fall at the facility on 03-18-2025 and was transported to the hospital, but the Licensing department had not received an Unusual Incident Report for R1’s fall and subsequent admission to the hospital.

ED provided a copy of the Unusual Incident Report to the LPA for R1’s fall on 03-18-2025 and a copy of the fax transmittal page that showed the Unusual Incident Report was successfully faxed to the Licensing department on 03-18-2025 at 4:01 PM.

ED stated that R1 had a fall on 03-18-2025 and a caregiver found R1 on the floor inside R1’s room in front of a chair. Care staff asked R1 if they could get up. R1 stated that they could not get up and said they were in pain. 911 was called and R1 was transported to the hospital. R1’s family and primary care physician (PCP) were notified.

ED further stated that R1 was not necessarily a fall risk, and prior to the fall on 03-18-2025, R1 had been falling on and off. However, there was never a need to call 911 since R1 had been able to get up and had not reported any pain.

Continued on LIC809-C

April CowanTELEPHONE: (650) 266-8889
Kiran JainTELEPHONE: (650) 416-4836
DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/02/2025
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ED stated that they spoke with R1’s family around 03-21-2025 or 03-22-2025. R1’s family told the ED that R1 was agitated in the hospital, screaming in pain, and the family was planning to place R1 on hospice. R1’s family called the ED on 03-24-2025 to share the news of R1’s passing and asked when they could empty R1’s room. There was no complaint from R1’s family about anything. The ED further stated that they did not have R1’s hospital discharge notes, as R1 did not return to the facility after being discharged from the hospital.

LPA reviewed R’s charting notes. On 01-24-2025 R1 had a fall in the hallway. R1 stated that they missed a step and fell down. R1 stated they didn’t hit their head nor were in pain. Care staff assisted R1 to stand up. On 03-11-2025, R1 fell from sitting on their walker while having lunch in the dining room. R1 stated they were ok, landed on their bottom, and didn’t hit their head. Care staff assisted R1 to sit back on the chair. R1’s family and PCP were notified.

LPA reviewed R1’s LIC602 Physician’s Assessment Report, dated 10/19/2022, which stated that R1 was non-ambulatory and was able to independently transfer to and from the bed.

LPA reviewed R1’s Functional Capabilities document, dated 02-22-2025, which stated that R1 used a walker and/or wheelchair.

No deficiencies were cited during today's visit.

An exit interview was conducted with the Executive Director. A copy of this report was provided to the Executive Director, Flavio Silva, whose signature on this form confirms receipt of the report.

SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran JainTELEPHONE: (650) 416-4836
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC809 (FAS) - (06/04)
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