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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202714
Report Date: 09/20/2022
Date Signed: 09/20/2022 04:48:09 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/20/2022 04:48 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 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: 65DATE:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Flavio SilvaTIME COMPLETED:
02:35 PM
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Licensing Program Analysts (LPA) Steve Chang conducted an annual inspection visit today. Upon arrival, the front desk staff conducted an infection control/prevention screening, and body temperature check, then logged LPA in visitor logs.

LPA met with Executive Director (ED) Flavio Silva. LPA addressed the purpose of today's visit to ED.

LPA toured the facility with ED. LPA inspected the dinning room of Assisted Living Unit and activity room. LPA inspected the resident apartment rooms of Assisted Living Unit. LPA inspected the dinning room and resident apartment rooms of Memory Care Unit. LPA inspected the public restrooms, kitchen, laundry room and some common areas. Some trash cans were observed without covers in some common areas. ED stated ED will put all the trash cans with covers in 3 days. All the common rest rooms were observed with the posters of washing hands for 20 seconds. PPE supplies were observed sufficient. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Fire extinguisher was serviced on 02/23/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors were tested by ED, and were working fine.

LPA observed the elevators had the hand sanitizers. LPA observed all the staff wore the masks. ED stated the facility already submitted the Infection Control Plan to CCL office.

No citation was issued for today's inspection. An exit interview was conducted with ED. This report was provided to ED to review. A copy of this report was provided to ED.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
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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