435202714-10-2-2024-26-AS-RMAO-DAHRDX-20241029125640

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202714
Report Date: 10/02/2024
Date Signed: 10/02/2024 11:47:19 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
04/16/2024 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20240416110730

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:	01:00 PM
MET WITH:	Felicia Barkley - Exec Director/Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff did not respond to residents’ requests for assistance in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced visit to deliver the finding of the complaint investigation received by the department. LPA with executive director/administrator Felicia Barkley and stated the purpose of the visit.

On 4/16/2024 - The Department received a complaint allegiing that staff did not respond to residents’ requests for assistance in a timely manner.

On 4/23/2024 - LPA Partoza, conducted the initial investigation and requested pendant call logs and Physician's Report (LIC 602) of residents and interviewed ED/ADM and the Facility Maintenance Director (FMD).

page 1 of 3, 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 4

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
04/16/2024 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20240416110730

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:	01:00 PM
MET WITH:	Felicia Barkley		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Licensee did not ensure complaint information was posted in facility as required.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced visit to deliver the finding of the complaint investigation received by the department. LPA with executive director/administrator Felicia Barkley and stated the purpose of the visit.

On 4/16/2024 - The Department received a complaint allegiing that licensee did not ensure complaint information was posted in facility as required.

On 4/23/2024 - LPA toured the facility with Facility Maintenance Director (FMD). FMD directed LPA to the Long Term Care Ombudsman (LTCO) and Community Care Licensinng (CCLD) complaint hotline posters.

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 4

Control Number 26-AS-20240416110730

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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The posters are located at the ground floor near the mail boxes and the parlor. Opposite the posters are other facility information required and issued by the city, county, state and federal agencies.

This agency has investigated the complaint alleging Licensee did not ensure complaint information was posted in facility as required. 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 deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with executive director/administrator Felicia Barkley and 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: 3 of 4

Control Number 26-AS-20240416110730

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 4/22/2024 at 10:08 a.m. LPA interviewed resident 1 (R1). R1 stated that the residents have pendant call buttons but are only allowed to use the pendant for an emergency. R1 stated on 4/10/2024 before lunch, R1 needed assistance to go to the restroom. R1 stated he/she followed the instruction called the receptionist and was told that a staff will be with R1 within 10 minutes. After 10 minutes RP stated that no one came and R1 called the reception area once again, but this time there was no answer and voicemail says the "voice mailbox is full and could not take any messages" and then the line went dead.

On 4/23/2024 at 2:55 pm. - LPA conducted an interview with Facility Maintenance Director (FMD). FMD stated "in terms of priority who ever pushed the pendant first will have the priority. FMD stated that the residents are encourage to call the reception area first for non immediate emergency and is not a life and death situation and does not require the facility to call 911.

On 8/29/2024 and 9/4/2024, LPA interviewed staff 1 to 3 (S1 to S3), 3 out of 3 stated the facility uses a pager and it alerts staff who needs assistance. 1 out 3 stated that the pager has a 2 to 3 minute delay, 2 out of 3 stated there's no delay. 3 out of 3 stated they respond within 10 minutes and 3 out of 3 stated sometimes there's a delay due to unavoidable circumstances such as a resident needing more time with assistance and at times staff is at the other end of the building causing delays.

On 9/4/2024, LPA interviewed 2 residents, in AL. 2 out of 2 stated they rarely use the pendant. The staff are pretty good at checking their needs. 1 out of 2 stated that staff response could be better but usually it's within 10, but it can go over 10 minutes. 1 out of 2 stated, the staff tries their best to be on time.

Based on document review, LPA observed that delays were for open windows, the loading dock door was open. Care staff are able to respond within 10 minutes once pendant is pressed by 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. Residents can use the pendant for incontinence assistance.

No deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with ED/ADM Felicia Barkley and 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 4