435202714-10-2-2024-26-AS-KHOS-DABP2Y-20241023105644

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202714
Report Date: 10/02/2024
Date Signed: 10/02/2024 11:20:08 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
12/28/2023 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20231228164703

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: 88	DATE:	10/02/2024
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Felicia Barkley		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility staff are verbally abusing resident.
Facility staff pushed resident to the toilet seat
Staff wrapped resident's undergarment too tightly which caused constriction of blood circulation
Facility staff physically abusing resident by splashing water on resident's face.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced visit to deliver a complaint investigation findings and met with administrator Felicia Barkley.

On 12/28/2023 The Department received a complaint alleging the facility staff are verbally abusing resident, facility staff pushed resident to the toilet seat. Staff wrapped resident's undergarment too tightly which caused constriction of blood circulation, facility staff physically abusing resident by splashing water on resident's face.

On 1/2/2024 - LPAs Simi Rai and Maria (Mita) Partoza, conducted interviews of staff (S1 to S6) inspected 5 resident bedroom, interview 5 residents in the memory care and requested physician's report, resident roster, staff roster and staff schedule.

page 1 of 4 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: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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 7

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
12/28/2023 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20231228164703

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: 88	DATE:	10/02/2024
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Felicia Barkley		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility shower temperature is not within regulation standards

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced visit to deliver a complaint investigation findings and met with administrator Felicia Barkley.

On 12/28/2023, the Departement received a complaint alleging the facilty shower temperature is not within standard.

On 1/2/2024 - LPAs Simi Rai and Maria (Mita) Partoza randomly inspected 5 resident bedroom and measured water temperature in 4 out of 5 resident room in Memory Care apartment/units. Water temperature for 4 out of 5 resident's room measured at 113.0 degree Fahrenheit to 117.5 degree Fahrenheit. 1 out of 5 was not measured because the resident was resting at the time of the visit.

page 1 of 2, See LIc 9099C

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: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 26-AS-20231228164703

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: 10/02/2024

NARRATIVE

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This agency has investigated the complaint alleging shower temperature is not within the standard. 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 deficiency were cited during today's visit based on California Code of Regulation (CCR) Title 22. An exit interview was conducted with current executive director/administrator (ED/ADM2) Felicia Barkley. A copy of the report was provided.

page 2 of 2
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: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 26-AS-20231228164703

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: 10/02/2024

NARRATIVE

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Facility staff are verbally abusing resident.
On 12/13/2023 - staff 11 (S11) reported to staff 12 (S12) regarding what he/she witnessed while in training. On 12/14/23, S12 escalated the incident to former executive director/administrator 1 (ED/ADM 1). On 12/16/23, S3 was coached regarding his/her approach with memory care (MC) residents.

On 1/2/2024 - LPAs Simi Rai and Mita Partoza, conducted interviews with staff 1 to 6 (S1 to S6).
S1 to S6 and stated they have not seen, or heard a staff be verbally abusive to resident in MC.

On 1/3/2024 - LPA conducted an interview with S11. S11 stated while shadowing he/she witnessed S3 to be mean and verbally abusive towards the resident. S11 stated "S3 did everything wrong." S11 stated, R2 and R3 are roommates and have witnessed S3 be verbally abusive to R2. S11 stated he/she reported what was witnessed to S12.

On 1/18/2024 - The facility conducted an interview with 4 staff (S14 to S17). 3 out of 4 stated that S3 was loud. 1 out of 4 stated S3 comes out as abrasive and blunt. 2 out of 4 stated they did not see or hear S3 to be verbally or physically abusive to residents.

On 4/27/2024, LPA Partoza interviewed ED/ADM 2 and stated S3 was placed on suspension and subsequently S3 was terminated. ED/ADM 2 stated the facility management investigated S3 regarding S3's approach with memory care residents and it did not align with the company policy.

On 9/4/2024 - LPA Mita Partoza, conducted additional staff interviews with 4 staff (S7 to s10). 1 out of 4 stated S3 was loud, lots of energy, 2 out of 4 stated S3 has a foul mouth and overheard S3 say to a resident that their private part is stinky, but does not remember the resident's name and when it happened. 4 out of 4 stated they did not see S3 to be physically abusive to resident.

page 2 of 4

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria Partoza	TELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 26-AS-20231228164703

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: 10/02/2024

NARRATIVE

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Facility staff pushed resident to the toilet seat

On 1/2/2024, LPAs Simi Rai and Mita Partoza, conducted an interview with S1 to S6, who stated they did not see or witness a staff push a resident to the toilet seat.

On 1/3/2024, LPA Partoza conducted an interview with S11 who stated while shadowing he/she witnessed S3 pushed R2 to the toilet seat while being verbally abusive to R2.

Staff wrapped resident's undergarment too tightly which caused constriction of blood circulation.
Based of interviews conducted by LPAs on 1/2/2024 of 6 staff (S1 to S6) stated they did not see or witness a resident's undergarment wrapped too tightly.

Based on interview conducted on 1/3/2024, S11 stated while shadowing S3, he/she witnessed S3 being abusive to R1 by wrapping resident's undergarment too tightly and double diapered R1.

Based on interview conducted by ED/ADM 1 on 1/18/2024, 4 staff (S14 to S17), they did not witness a resident's undergarment wrapped too tightly.

Facility staff physically abusing resident by splashing water on resident's face.
On 1/2/2024, LPAs Simi Rai and Mita Partoza, conducted an interview of 6 staff, S1 to S6.
Based on the interview 6 out of 6 stated they did not witness any staff to be physically abusive to resident, by splashing water on resident's face.

On 1/3/2024 S11 stated on an email that he/she "observed a caregiver splash water on resident's face and was too rough with the resident."

Based on document review, S11 reported the incident to S12. S12 escalated the incident to ED/ADM 1 and an internal investigation was conducted.

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: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 26-AS-20231228164703

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: 10/02/2024

NARRATIVE

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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 deficiency was cited during today' visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with current executive director / administrator (ED/ADM 2) Felicia Barkley. 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: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC9099 (FAS) - (06/04)

Page: 7 of 7