435202714-9-11-2024-26-AS-RMAO-D9BUEM-20240921153122

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202714
Report Date: 09/04/2024
Date Signed: 09/11/2024 10:14:46 PM

Unfounded

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
10/31/2023 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20231031153118

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:	09:15 AM
MET WITH:	Felicia Barkley Executive Director/Administrator		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Staff cut resident hair without consent.
Staff provided a massage to a resident, which caused the resident neck pain.
Staff are retaliating against residents

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 10/31/2023, the Department received a complaint stating that the staff cut the resident hair without consent, staff massage the resident which caused neck pain and staff are retaliating against the resident.

On 11/09/2023 - LPA conducted a complaint investigation, requested for documents to be reviewed and conducted interviews with staff and resident.

page 1 of 4 see LIC9099C

Unfounded

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 4

Control Number 26-AS-20231031153118

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 11/9/2023 LPA, Monter interviewed R1 and stated that a facility staff (S1) gave him/her a massage by the hallway because of a sprained neck and was very rough. R1 stated he/she does not remember when the massage took place. R1 stated S2 and S3 witnessed S1 give him/her a massage R1 stated he/she complained and reported S1 to the former executive director (ED) and S1 retaliated against him/her by cutting his/her hair while in a deep sleep.

Staff cut resident's hair without consent.

On 11/09/2023 LPA Monter interviewed staff 3 (S3). S3 stated he/she did not see R1s hair was cut. S3 stated R1 sees people who are not there.

On 11/09/2023 LPA Monter interviewed staff 4 (S4), S4 stated R1 is very confused and would say someone is chasing him/her and trying to hurt him/her.

On 4/27/2024 LPA Partoza, continued with the investigation and interviewed former Executive Director (ED) by phone. Former ED stated staff do not carry scissors and does not go in the resident's room without knocking first and getting a consent to come in. ED stated that R1 experience confusion and hallucination. R1 is diagnosed with alopecia that causes hair loss. Former ED stated, the next day (10/20/2023) he/she visited R1 and asked R1 if he/she recognized the staff that cut his/her hair, R1 stated to ED that he/she does not know what former ED is talking about.

On 5/18/2024 LPA Partoza interviewed staff 2 (S2) by phone. S2 stated that on 10/19/2023, after 10:00 p.m. R1 called S2 to report that a staff, while in deep sleep cut R1s hair. R1 indicated to S2 that S1 was the one who cut his/her hair. S2 stated he/she did not see any cut hair on the floor or the bed, S2 stated that R1 has medication for his/her head/hair irritation.

On 8/28/2024 LPA Partoza, interviewed staff 1(S1) by phone and stated that he/she does not go inside a resident room without permission. S1 stated as staff he/she is not allowed to carry scissors and no scissors are allowed inside the resident's apartment.

page 2 of 4 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: 3 of 4

Control Number 26-AS-20231031153118

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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Staff provided a massage to a resident, which caused the resident neck pain.

On 11/09/2023, LPA Monter interviewed R1 and stated that S1 gave him/her a massage without permission and was very rough and caused neck pain. It was witnessed by two other staff (S2 and S3). R1 stated he/she does not remember when the massage took place and only remember that it was in the afternoon.

On 11/09/2023, LPA Monter interviewed S3, S3 stated he/she did not see S1 give R1 a massage. S3 stated that he/she heard, that S1 massaged R1 because her neck was hurting. S3 stated that R1 suffers from confusion and sees people who are not there.

On 11/09/2023, LPA Monter interviewed S4, S4 stated he/she works in the AM shift and did not witness S1 giving R1 a massage. S4 stated R1 has never asked S4 for a massage.

On 11/09/2023 LPA Monter, interviewed former ED. Former ED stated R1 came by the office and told ED S1 gave him/her a massage and it still hurt and asked R1 for details. Former ED met with S1 and S1 stated R1 complained of a neck pain and asked if R1 wanted a massage and R1 stated yes.

On 4/27/2024, LPA Partoza, continued with the investigation and interviewed former ED and stated S1 asked R1 and R1 consented to the massage. After the massage, R1 complained to former ED of a neck pain and stated the pain did not go away. The following day R1 stated to former ED that his/her neck no longer hurts and the massage felt good.

On 5/18/2024 , LPA Partoza, interviewed S2 and stated on the day of the incident (10/19/2023), R1 went to S2 for pain medication and stated that his/her neck was in a lot of pain. S2 stated R1 came back and asking for more pain medication for neck pain. S2 stated the following day, S2 observed R1 was fine and no more neck pain.

On 8/28/2024, LPA Partoza, interviewed S1, by phone and stated he/she did not give massage or neck rub to R1. R1 complained he/she was in pain. S1 gave R1 a side hug and was really careful because R1 was in pain. S1 stated R1 is confused most of the time.

page 3 of 4 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 4

Control Number 26-AS-20231031153118

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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Staff are retaliating against residents
On 11/9/2023, LPA Monter interviewed S3 who stated "I don’t work with S1 at all" and only sees S1 during shift change which lasts 5 minutes.

On 11/09/23, LPA Monter interviewed S4 who stated he/she worked with R1. S4 stated R1 sees things that are not there. S4 stated R1 would say someone is chasing him/her and trying to hurt him/her.

On 4/27/2024 LPA Partoza, interviewed by phone former ED who stated S1 did not retaliate against R1. Former ED stated R1 have episodes of confusion.

On 5/18/2024, LPA Partoza, interviewed S2 by phone who stated stated after the incident S1 stayed away from R1 and was fearful of R1. S2 stated R1 is confused and was not sure if it was S1 or another person who retaliated against him/her.

On 8/28/2024, LPA Partoza interviewed S1 by phone and stated he/she does not retaliate at anyone. S1 stated R1 made him/her uncomfortable because R1 followed him/her around while working. S1 stated after that he/she stayed away from R1.

Based on document reviews and interviews, R1 is diagnosed with mental disorder that contributed to R1s behavior. R1 is diagnose with head/hair irritation.

This agency has investigated the complaint alleging staff cut resident hair without consent, staff provided a massage to a resident which caused the resident pain, and staff are retaliating against resident. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

No citations were issued during today's visit based on the California Code of Regulations Title 22. An exit interview was conducted with current Executive Director/Administrator Felicia Barkley. A copy of the report was provided.

Page 4 of 4 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)

Page: 4 of 4