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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200731
Report Date: 05/26/2021
Date Signed: 05/28/2021 01:27:11 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:
05/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Byron PerrymanTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced infection control site visit today. LPA met with the Executive Director (ED) Byron Perryman.

One central entry point was designated for all staff, residents, and visitors. A temperature screening station, sign in sheet, and COVID-19 questionnaire were present at the entrance. Hand sanitizing stations were present. LPA was checked in by the receptionist before the tour. LPA toured the facility with ED.

The facility was observed to be in sanitary condition. All staff members were observed to be wearing masks.

All restrooms observed to be adequately stocked with paper towels and hand soap.

Facility was observed to have adequate supply of PPE in the storage area. A plan for epidemic outbreak specific to COVID-19 mitigation plan report (LIC 808) was in file.

No deficiency cited during visit.

This report was reviewed with ED and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
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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