435202714-9-11-2024-26-AS-RMAO-D9BUKN-20240921153925

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202714
Report Date: 09/04/2024
Date Signed: 09/11/2024 10:44:11 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/13/2023 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20231013103238

FACILITY NAME:	ATRIA EVERGREEN VALLEY		FACILITY NUMBER:	435202714
ADMINISTRATOR:	FLAVIO SILVA		FACILITY TYPE:	740
ADDRESS:	4463 SAN FELIPE ROAD		TELEPHONE:	(408) 532-7677
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	134	CENSUS: 89	DATE:	09/04/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Felicia Barkley - Executive Director/Administrator		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Facility is overcharging resident for services

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced visit to continue the investigation of the above allegation and met with current Executive Director Felicia Barkley.

On 10/13/2023, the Department received a complaint that the facility is overcharging the resident (R1) for services.

On 5/12/2023, resident (R1) was admitted to the facility with a level 2 care for his/her neurocognitive disorder. On 7/1/2023, R1 was found at the parking lot and was looking for his/her car placing himself/herself in danger, 911 was called and prompted the facility to make a determination to increase R1s level of care.

page 1 of 2 see LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 26-AS-20231013103238

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 VALLEY	FACILITY NUMBER: 435202714
	VISIT DATE: 09/04/2024

NARRATIVE

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Based on responsible party's (RP) statement and interview, RP visited the facility and was informed that R1 walked out of the facility unassisted and later received an email that the facility is hiring a company to provide a 1 on 1 care for R1.

Based on a written statement by RP, on 7/3/2023 RP set a meeting with the facility to discuss options for the 1 on 1 care services for R1. On 7/5/2023 RP met with former Memory Care Director (MCD) and was given two option, either to move R1 to a memory care which will cost $5500 per month or a 1 on 1 care in the assisted living unit and will cost $33,000 a month or $1,100 per day, 24/7. RP agreed to transfer R1 to memory care on 7/6/2023 and signed the room change addendum for R1 on 7/5/2023. RP stated he/she assumed that 1 on 1 care service will be stopped by MCD for R1 once R1 transfers to memory care.

RP stated, the facility is charging the RPs $19,000 for R1's 1 on 1 care from 7/1/2023 to 7/18/2023. RP stated he/she did not agree for the 1 on 1 to continue after 7/6/2023. RP stated he/she were not notified that 1 on 1 care service continued for R1 up to 7/18/2023. RP stated former ED/ADM called and explained why R1 needs a 1 on 1 care even though R1s moved to memory care unit.

On 10/19/2023, LPA Rai interviewed the former Executive Director/Administrator (ED). Former ED stated that R1 has 1 on 1 care service that started on 7/4/2023 and ended on 7/18/2023. ED stated the 1 on 1 continued up to 7/18/2023 because R1 continues to have agitation even in the memory care unit. Former ED stated the facility determines the need for 1 on 1 service if the resident continues to have a behavior.

On 10/19/2023, LPA Rai interviewed the Community Business Director (CBD) and stated that 1 on 1 care services is through a third party and not provided by the facility. CBD stated because R1 was initially admitted with his/her spouse, the charges are billed under one account. CBD stated that all services are itemized and listed on the invoice including the 1 on 1 care.

On 4/27/2024, LPA Partoza continued with the investigation and, interviewed former ED, who stated the family was in agreement with the 1 on 1 care for R1, which was provided by a third party, The Key. The contract is with the third party and not with the facility. Former ED stated when RP received the invoice from their business center the 1 on 1 care service amounted to $19,000. Former ED stated the facility met with RP and settled on sharing the cost. Former ED stated the facility paid $9,000 and $10,000 was left for RP to pay.

page 2 of 3 See LIC 9099C

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20231013103238

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 VALLEY	FACILITY NUMBER: 435202714
	VISIT DATE: 09/04/2024

NARRATIVE

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On 8/22/2024, LPA Partoza, interviewed RP. RP stated they had a meeting the week after 7/18/2023 with former ED. The $19,000 1 on 1 care service payment was settled between the facility and RP. RP stated the family settled their portion of the balance.

On 8/29/2024 LPA Partoza, interviewed current Executive Director/Administrator (ED2), and stated the meeting between the facility and the RP to settle the bill occurred on 3/2/2024 and the amount was settled middle of March 2024.

Based on the review of admission agreement "if residents become a safety risk to self and others during their residency, the facility have the right at their sole determination, at the resident's expense, private duty personnel to provide supervision or assistance...The facility will communicate the decision on behalf of the resident to the respective responsible party and will occur in advance, if reasonably possible..."

Based on document review and interview the facility's business center listed the services based on the admission agreement according to the level of care for R1 and his/her spouse. The 1 on 1 care service charges were adjusted and resolved.

Based on document review, interviews and admission agreement, the facility provided the basic services of R1. As stipulated on the admission agreement optional services may be purchased by residents. If the level of care provided by the facility no longer is appropriate for the resident's needs, the facility will implement a change in the level of care and will consult the change with the resident or their responsible parties.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies were cited during today's visit based on California Code of Regulations Title 22. An exit interview was conducted with current ED/ADM Felicia Barkley and a copy of the report was provided.

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END OF REPORT

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC9099 (FAS) - (06/04)

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