435200731-3-1-2024-26-AS-KHOS-D3ANF9-20240312102510

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200731
Report Date: 02/29/2024
Date Signed: 03/01/2024 10:46:03 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/17/2021 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210817170716

FACILITY NAME:	ATRIA SUNNYVALE		FACILITY NUMBER:	435200731
ADMINISTRATOR:	BYRON PERRYMAN		FACILITY TYPE:	740
ADDRESS:	175 E REMINGTON DR		TELEPHONE:	(408) 738-3410
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	160	CENSUS: 88	DATE:	02/29/2024
		UNANNOUNCED	TIME BEGAN:	01:29 PM
MET WITH:	Cathy Platon		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff caused an injury to a resident while in care due to abuse

INVESTIGATION FINDINGS:

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On 2/29/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegation. LPA met with Resident Services Director Cathy Platon.. LPA explained the purpose of the visit.

Regarding the allegation of staff caused an injury to a resident while in care due to abuse, the Reporting Party (RP) stated that the suspected abuser (SA) moved the resident (R1) from the wheelchair to the bed. In doing so, the SA grabbed the resident with enough pressure that it left a bruise on the client.

During the course of the investigation, LPA Ng was able to interview R1 and mentioned that they don’t remember who the caregiver was who helped with the transfer. R1 also felt that was not doing it on purpose. R1 still felt safe in the facility. A staff member (S1) who was on duty at this time, mentioned that they did not believe there was an abuse by staff. Three other staff members who were interviewed has denied seeing any resident being abused in the facility. Another staff, S2, also mentioned that a retraining would be conducted by home health agency nurse to train the caregivers the proper way to assist residents getting up safely.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

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-20210817170716

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: ATRIA SUNNYVALE	FACILITY NUMBER: 435200731
	VISIT DATE: 02/29/2024

NARRATIVE

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Based on records review, a report was submitted which stated that, it was determined that there were no signs of abuse and that R1 felt safe in the facility. The facility also conducted in-service training to train the caregivers the proper way for resident transfers.

Based on interviews & records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Report is reviewed and copy is provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

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