435200731-10-13-2021-26-AS-SYIP-C7YT4Y-20211020142441

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200731
Report Date: 10/12/2021
Date Signed: 10/13/2021 01:27:43 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
08/24/2020 and conducted by Evaluator Yatfai Ng

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20200824152536

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: 94	DATE:	10/12/2021
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Byron Perryman		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Lack of supervision resulting in residents being assaulted by another resident.

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 8/27/2020, an initial unannounced tele-investigation was conducted. On 6/8/2021, LPA conducted a subsequent investigation. LPA interviewed 1 resident and 6 staff. However, the resident (R1) was not able to recall that incident.

Unsubstantiated

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: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

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-20200824152536

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: 10/12/2021

NARRATIVE

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On 6/8/2021, 6 staff were interviewed. LPA was unable to interview the third staff on duty as the staff did not return LPA’s calls. 6 out of 6 staff denied there was a lack of supervision in facility and that staff responded to this incident within a minute. Staff stated they had 3 staff and a med-tech on duty for AM & PM shift and 2 staff and 1 med tech for the NOC shift. Residents were checked every 2 hours but has since increased monitoring to every hour for R2 who has sundowning.

Based on interview with the staff (S1) who was on duty during the incident, S1 was at the scene within 1 minute and observed R1 on the floor with minor bump on forehead.

The police report reviewed noted that the staff (S2) who also was on duty during the incident responded to the incident right after the altercation took place. R1 was interviewed by the police and disclosed that a male staff came into R1’s room but R1 told him to leave. The male staff got angry and pushed R1 down. Per the police report, R2, the suspect, a resident, was also being interviewed by the police but was unable to provide any accurate information due to dementia. The police report also stated that this case was determined to be inactive as both residents (R1 & R2) involved in this incident are diagnosed with dementia.

Staff schedule record review confirmed 3 staff and 1 med-tech on duty for AM & PM shift on day of incident.

This Department has investigated the above allegation. Based on interviews and record review, the Department found that the above allegation is UNSUBSTANTIATED. Unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

This report was reviewed the 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: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

LIC9099 (FAS) - (06/04)

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