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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200731
Report Date: 02/05/2021
Date Signed: 02/26/2021 01:33:00 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:BYRON PERRYMANFACILITY TYPE:
740
ADDRESS:175 E REMINGTON DRTELEPHONE:
(408) 738-3410
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:160CENSUS: 93DATE:
02/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:26 PM
MET WITH:Byron PerrymanTIME COMPLETED:
03:58 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 Executive Director (ED) Byron Perryman.

The purpose of visit today was to conduct a health and safety check, to respond to an incident report that was sent to the Community Care Licensing Department on 2/3/2021. The incident report revealed that R1 was touched inappropriately by R2.

LPA interviewed ED and R1.

It was noted R1 was placed on the first floor while R2 was placed in second floor. An escort service was utilized to ensure the safety for R1. R1 had not seen R2 since the incident. R1 felt safe and satisfied with the service provided by the facility.

This case management remained open pending additional reports.

No deficiency cited during visit.

This report was emailed to the ED 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: 02/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021
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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