435202714-6-21-2021-26-AS-SYIP-C4NVC7-20210706161839

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202714
Report Date: 06/18/2021
Date Signed: 06/21/2021 09:57:31 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/04/2021 and conducted by Evaluator Anna Bui

COMPLAINT CONTROL NUMBER: 26-AS-20210304153212

FACILITY NAME:	ATRIA EVERGREEN VALLEY		FACILITY NUMBER:	435202714
ADMINISTRATOR:	ERNIE GETUIZA		FACILITY TYPE:	740
ADDRESS:	4463 SAN FELIPE ROAD		TELEPHONE:	(408) 532-7677
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	134	CENSUS: 73	DATE:	06/18/2021
		UNANNOUNCED	TIME BEGAN:	12:17 PM
MET WITH:	Alice Nghiem, Activities Director		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Staff spoke inappropriately to resident.

INVESTIGATION FINDINGS:

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On 06/18/2021 at 12:17 pm, Licensing Program Analyst (LPA) Anna Bui conducted an unannounced complaint investigation visit to deliver the finding to the above allegation. LPA met with Alice Nghiem, Activities Director. Andy Anaya, Executive Director, joined via telephone.

Between 03/15/2021 – 05/17/2021, 5 staff were interviewed. 1 out of 5 staff witnessed staff speaking loudly to a resident. 2 out of 5 staff stated they heard directly from residents that a staff spoke inappropriately to them. 1 out of 5 staff admitted to raising their voice at a resident.

Between 03/15/2021 – 05/17/2021, 8 residents were interviewed. 2 out of 8 residents stated they did not like what staff said to them. 1 out of 8 residents stated a staff spoke inappropriately to a resident.

-Continued, see LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

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 5

Control Number 26-AS-20210304153212

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ATRIA EVERGREEN VALLEY	FACILITY NUMBER: 435202714
	VISIT DATE: 06/18/2021

NARRATIVE

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The Department has conducted an investigation of the above allegation. Based on interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

A deficiency is being cited. See LIC 9099-D.

Exit interview was conducted with Alice Nghiem, Activities Director and Andy Anaya, Executive Director. This report, LIC 9099-D, and Appeal rights were discussed with Alice Nghiem, Activities Director, and Andy Anaya, Executive Director, and a copy was provided to Alice Nghiem, Activities Director.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20210304153212

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ATRIA EVERGREEN VALLEY	FACILITY NUMBER: 435202714
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/25/2021 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents... (a) Residents… shall have all... personal rights: (1) To be accorded dignity… with staff, residents, and other persons. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	S1 is no longer at the facility. Licensee agreed to conduct staff training on safeguarding residents’ personal rights and will submit staff training schedule on personal rights to CCL by POC date.
	8 9 10 11 12 13 14	Based on interviews, staff (S1) spoke inappropriately to resident (R1) and did not treat resident (R1) with dignity. This posed a potential risk to the residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/04/2021 and conducted by Evaluator Anna Bui

COMPLAINT CONTROL NUMBER: 26-AS-20210304153212

FACILITY NAME:	ATRIA EVERGREEN VALLEY		FACILITY NUMBER:	435202714
ADMINISTRATOR:	ERNIE GETUIZA		FACILITY TYPE:	740
ADDRESS:	4463 SAN FELIPE ROAD		TELEPHONE:	(408) 532-7677
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	134	CENSUS: 73	DATE:	06/18/2021
		UNANNOUNCED	TIME BEGAN:	12:17 PM
MET WITH:	Alice Nghiem, Activities Director		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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9

Staff not properly managing resident's medications.

INVESTIGATION FINDINGS:

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On 06/18/2021 at 12:17 pm, Licensing Program Analyst (LPA) Anna Bui conducted an unannounced complaint investigation to deliver the finding to the above allegation. LPA met with Alice Nghiem, Activities Director. Andy Anaya, Executive Director, joined via telephone.

Between 03/15/2021 – 05/17/2021, 3 staff were interviewed. 3 out of 3 staff stated staff managed residents’ medications as prescribed. 3 out of 3 staff stated when there was a doctor’s order for changes to medications, residents were notified of the change. 3 out of 3 staff stated staff followed new doctor’s order on the same day it was received.

-Continued, see LIC 9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

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 5

Control Number 26-AS-20210304153212

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: ATRIA EVERGREEN VALLEY	FACILITY NUMBER: 435202714
	VISIT DATE: 06/18/2021

NARRATIVE

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Between 03/15/2021 – 05/17/2021, 8 residents were interviewed. 8 out of 8 residents stated they receive the same medications around the same time every day. 7 out of 8 residents stated either there have been no changes to their medications or staff informed them when there were changes to their medications. 1 out of 8 residents stated staff did not inform them of medication changes.

On 05/21/2021, R1’s hospice nurse (H1) was interviewed. H1 stated R1 was notified of medication changes. H1 stated doctor’s order was given to the facility and changes were made the same day.

Facility’s records were reviewed. Medication Administration Record (MAR) was reviewed for 8 residents for March 2021. 8 out of 8 residents’ MAR showed they were given their medications as directed on the MAR. A review of R1’s medical records showed the facility followed doctor’s orders the same day the order was received.

The Department has investigated the above allegation. Based on interviews and records review, the Department has determined that the allegation was UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No deficiencies were cited during today’s visit.

Exit interview was conducted with Alice Nghiem, Activities Director and Andy Anaya, Executive Director. This report was reviewed with Alice Nghiem, Activities Director, and Andy Anaya, Executive Director, and a copy of this report was left Alice Nghiem, Activities Director.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

LIC9099 (FAS) - (06/04)

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