435202714-10-3-2024-26-AS-KHOS-DABPBK-20241023111028

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202714
Report Date: 10/02/2024
Date Signed: 10/03/2024 12:12:14 AM

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
08/27/2024 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20240827103323

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:	09:00 AM
MET WITH:	Felicia Barkley		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Facility did not identify resident's need prior to admission that resulted to eviction.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced visit to deliver the complaint findings and met with executive director/administrator (ED/ADM) Felicia Barkley and stated the purpose of the visit.

On 8/27/2024, the Department received a complaint alleging the facility did not identify resident's need prior to admission that resulted to eviction.

On 8/29/2024, LPA Partoza, conducted an initial investigation, interviewed staff, residents and requested for documents.

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: 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 2

Control Number 26-AS-20240827103323

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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On 9/4/2024, LPA Partoza, interviewed resident 1 (R1). R1 stated prior to moving in to the facility. R1 was assessed and the facility was aware that R1 uses an assistive device to transfer and does not require a two person assist when transferring.

On 8/29/24 and 9/4/2024, LPA interviewed 3 staff, 3 out of 3 staff stated that R1 did not need a two person assist.

Based on review of the facility's pre-admission assessment dated 12/31/2023, and reappraisal assessment dated 01/31/2024, the facility is able to meet the need of the resident.

On 7/12/2024, based on record review, R1 was re-assessed by the Resident Services Director (RSD), and stated on the report that R1 required extensive assistance with dressing, continence, and transfer ability.

Based on document reviews, R1's level of care has changed from the date the resident moved in to the facility to the date R1 was re-assessed. Based on the assessment the Community can no longer meet the need of the resident.

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 are being cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Executive Director/Administrator (ED/ADM) 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: 2 of 2