435200731-6-8-2021-26-AS-KHOS-C3TLKH-20210609084935

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200731
Report Date: 06/08/2021
Date Signed: 06/08/2021 05:14:00 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/24/2020 and conducted by Evaluator Yatfai Ng

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20200624141106

FACILITY NAME:	ATRIA SUNNYVALE		FACILITY NUMBER:	435200731
ADMINISTRATOR:	SILVA, FLAVIO		FACILITY TYPE:	740
ADDRESS:	175 E REMINGTON DR		TELEPHONE:	(408) 738-3410
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	160	CENSUS: 92	DATE:	06/08/2021
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Byron Perryman		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility staff are not following resident's dietary needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced subsequent complaint investigation visit to deliver the finding of the complaint. LPA met with the Executive Director Byron Perryman.

On 7/3/2020, an initial unannounced investigation was conducted. LPA interviewed 1 staff and obtained a copy of residents' dietary plan. On 10/13/2020, LPA interviewed 1 family member of the alleged victim. LPA also obtained a copy of residents’ roster of last 10 years from the facility.

On 10/13/2020, 1 family member of the alleged victim was interviewed. 1 out of 1 family member stated the alleged victim did not stay in this facility but another facility.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

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-20200624141106

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 SUNNYVALE	FACILITY NUMBER: 435200731
	VISIT DATE: 06/08/2021

NARRATIVE

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Based on record review, the residents’ roster from 1/1/2010 to 10/13/2020 showed that there was no such person named as the alleged victim in the facility.

Based on interview and record review, the Department had found that the above allegation was UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

This report was reviewed with Executive Director. A copy of this report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

LIC9099 (FAS) - (06/04)

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