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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202714
Report Date: 04/07/2021
Date Signed: 04/07/2021 02:41:44 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:ERNIE GETUIZAFACILITY TYPE:
740
ADDRESS:4463 SAN FELIPE ROADTELEPHONE:
(408) 532-7677
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:134CENSUS: 79DATE:
04/07/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Ernie Getuiza, Executive DirectorTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Anna Bui conducted an unannounced Case Management – Incident tele-visit today. Due to COVID-19 health pandemic, LPA met with Ernie Getuiza, Executive Director (ED), via facetime.

The purpose of this visit is to follow up on an incident report that Community Care Licensing (CCL) received on 03/15/2021 regarding a resident’s (R1) missing ring.

R1’s LIC 621 (Resident Personal Property and Valuables) was reviewed. R1 did not disclose that she had a ring when she moved in. R1's missing ring was documented on R1's LIC 9060 (Resident Theft and Loss Record).

LPA interviewed Ernie Getuiza, Executive Director (ED) and Diane Martinez, Resident Services Director (RSD), regarding R1’s incident. RSD stated that R1 told her she did not disclose the ring when she moved in and she did not remember the last time she saw the ring. ED and RSD stated that they were not aware of R1 having a ring. ED stated that they will continue to remind residents that they can document personal property and valuables on the LIC 621.

No deficiencies cited during today’s visit.

An electronic copy of LIC 809 was emailed to Ernie Getuiza, Executive Director, to review and sign on 04/07/2021.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna BuiTELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021
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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