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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202714
Report Date: 07/24/2024
Date Signed: 07/24/2024 03:42:48 PM


Document Has Been Signed on 07/24/2024 03:42 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
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: 100DATE:
07/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Felicia Barkley Exec Director/AdministratorTIME COMPLETED:
03:45 PM
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On 7/24/2024, Licensing Program Analysts (LPAs) Maria (Mita) Partoza and Marcela Yanez, conducted an unannounced case management for incident report regarding elder abuse. LPAs met with Executive Director/Administrator (ED/ADM) Felicia Barkley and stated the purpose of the visit.

The facility serves adults 60 years old and over and is a Residential Care Facility for the Elderly (RCFE) the facility is approved for 134 non-ambulatory and delayed egress. Hospice waiver for 13.

LPAs requested the following documents from ED/ADM; LIC 500, LIC 602 , LIC 625, resident roster, staff contact information, responsible party (RP) for resident (R1) and training log for S1 and S2. ED/ADM provided the Police Department Case number. Other documents requested will be emailed to LPA such as training logs, statement of S1 and S2 pre-appraisal and appraisal needs and services plan for R1.

Based on interview, ED/ADM stated that S2 heard R1 scream and came to see what was happening. ED/ADM stated that S2 witnessed S1 holding down R1 and forcing R1 to seat down. ED/ADM stated this happened around 6:00 p.m. of 7/20/2024 inside the common area/activity room. ED/ADM stated an internal investigation was conducted on 7/22/2024 and ED/ADM interviewed S1 and S2. S1 and S2 both gave statement to ED/ADM. ED/ADM stated that, S1 was suspended until internal investigation findings are finalized. ED/ADM stated that S2 reported the incident on 7/21/2024 by calling ED/ADM.

Based on the following information gathered during the investigation, this case management will remain open for further investigation. No deficiencies were cited during today's visit. An exit interview was conducted with ED/ADM Felicia Barkley and a copy of the report was provided.

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End of report
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
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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