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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202714
Report Date: 08/18/2020
Date Signed: 08/18/2020 04:00:22 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 EVERGREEN VALLEYFACILITY NUMBER:
435202714
ADMINISTRATOR:CABUENA, JAIRUSFACILITY TYPE:
740
ADDRESS:4463 SAN FELIPE ROADTELEPHONE:
(408) 532-7677
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:134CENSUS: 93DATE:
08/18/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jairus "Jett" Cabuena, Executive DirectorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Jackie Jin conducted a Tele-visit due COVID-19 pandemic. This case management visit was regarding a death that was reported to the Department. LPA met with Jett Cabuena, Executive Director.

During tele-visit LPA discussed the incident and interviewed the staff. Police report number was obtained. LPA requested Executive Director to follow up with resident's family member regarding death certificate and coroner's report and send a copy to CCL.

This report was reviewed with Jett Cabuena, Executive Director, and a copy of this report will be emailed to Jett Cabuena, Executive Director on 08/18/2020 for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2020
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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