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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200731
Report Date: 06/10/2022
Date Signed: 06/10/2022 03:05:02 PM


Document Has Been Signed on 06/10/2022 03:05 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
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: 95DATE:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Byron PerrymanTIME COMPLETED:
03:15 PM
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On 06/10/2022, Licensing Program Analysts (LPAs)Mandeep Kaur and David Marrufo conducted an unannounced infection control site visit today. LPAs met with the Executive Director (ED) Byron Perryman.

A temperature screening station, sign in sheet, and COVID-19 questionnaire were present at the entrance. Hand sanitizing stations were present. LPAs were checked in by the receptionist before the tour. LPAs toured the facility with ED.

All staff members were observed to be wearing masks.
Staging Room was observed clean and in good repair on 2nd floor of the facility.

2 of the common restrooms observed to be adequately stocked with paper towels and hand soap.

The main kitchen was inspected. There was sufficient perishable food for at least 2 days and nonperishable food for at least one week. Food was observed being prepared in a safe and healthful manner.

Facility was observed to have adequate supply of PPE in the storage area in the ED office.

The facility's Life Guidance Neighborhood (Memory Care) was toured. 2 of the common restrooms observed to be adequately stocked with paper towels and hand soap within the memory care unit as well.
.
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) 726-4986
LICENSING EVALUATOR NAME: Mandeep KaurTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
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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