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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202714
Report Date: 09/20/2024
Date Signed: 09/20/2024 04:59:56 PM


Document Has Been Signed on 09/20/2024 04:59 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: 89DATE:
09/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Felicia Barkley - Executive DirectorTIME COMPLETED:
05:00 PM
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Licensing Program Analysts (LPA) Maria Partoza and Santino Fortes conducted an unannounced annual inspection with Administrator Felicia Barkley (ADM). ADM informed that facility has 18 memory care and 71 assisted living residents.

LPAs toured the facility inside and out including: kitchen, dining room, and 3 memory care resident rooms and 5 Assisted living rooms. Restrooms observed to have non-skid flooring. LPAs observed perishable food supply of at least two days and non-perishable food supply of at least seven days. Refrigerator temperature was observed at 38 degrees F and Freezer temperature was 0 Degrees F. The front yard and back of the facility was also inspected. LPA observed that walkway leading from the back has no fencing and opens to the parking lot. There was no obstructions blocking the outdoor exits. LPA observed Facility License and Resident Personal rights were posted in public view.

LPA observed the medication storage area with first aid kit, knives storage area, and cleaning product storage area as locked and inaccessible to clients in care. Room temperature was at 73 degree F, and hot water temperature was measured from resident bathroom at 105.8 degrees F. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors functioned properly when tested. Fire extinguishers were last serviced on 9/5/2024. The facility conducts their fire drills quarterly.

LPA reviewed facility records for 6 staff and 10 clients. LPA reviewed 5 clients medications and centrally stored medication records and were found to be updated..

No deficiencies were cited during today's visit as per California Code of Regulations Title 22. Exit interview was conducted with ADM. ADM reviewed the report and a copy was provided to ADM for signature.

SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Santino FortesTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
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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