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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202714
Report Date: 04/27/2024
Date Signed: 04/28/2024 02:10:47 AM


Document Has Been Signed on 04/28/2024 02:10 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:ATRIA EVERGREEN VALLEYFACILITY NUMBER:
435202714
ADMINISTRATOR:FLAVIO SILVAFACILITY TYPE:
740
ADDRESS:4463 SAN FELIPE ROADTELEPHONE:
(408) 532-7677
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:134CENSUS: 84DATE:
04/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Felicia Barkley - Executive DirectorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced case management for incident reported on 4/15/2024. This incident occurred on 4/14/2024 for medication error. LPA met with Executive Director (ED) Felicia Barkley.

The report stated that facility Medication Technician (MT) gave resident (R1) the wrong medication on April 14, 2024 that happened in the morning during breakfast. R1s physician and family were notified. There was no side effects or adverse reactions reported or observed. Facility staff monitored R1 for any changes in condition after the incident. The frequency of monitoring by staff was every two hours.

During today's visit, LPA Partoza interviewed ED. ED stated she was notified by the Resident Service director who was notified by the staff regarding the medication error and upon investigation it was discovered that the medication error was caused by a human error. ED stated that MT was given a final warning.

ED will email LPA Partoza the requested documents from ED a copy of S1s training records and the length of observation for R1.

This case management will be kept open pending investigation.

Exit interview conducted with ED Felicia Barkley and a copy of this report provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2024
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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