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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202714
Report Date: 10/30/2023
Date Signed: 10/30/2023 02:41:36 PM

Document Has Been Signed on 10/30/2023 02:41 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: 85DATE:
10/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Administrator Flavio SilvaTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Monter conducted an unannounced case management visit regarding an incident report. LPA met with (ADM) administrator Flavio Silva & explained the purpose of the visit.

On October 27, 2023, the Department received an in incident report stating resident, R1 had consumed a cleaning solution. R1 reported that his/her throat was sore, and facility staff called 911. R1 was transported to a hospital. R1 returned the same day with no change of orders.

On October 30, 2023, LPA interviewed resident R1 in the Assisted Living Unit. R1 stated he/she was feeling better. With R1’s permission, LPA conducted an inspection of R1’s apartment. LPA did not find cleaning solutions and other items that could pose hazard to R1.

LPA interviewed ADM. ADM stated R1 moved into the facility on May 15, 2023. ADM stated R1 resides in assisted living unit and requires minimal assistance when it comes to ADL's. ADM stated R1 manages his/her own medications. ADM stated R1 has not shown any signs of a change of condition in the past 5 months. R1's responsible party was informed about incident. A 2-hour check on the resident was in place as of 10/27/2023. LPA recommend to ADM to maintain the monitoring of every two hours is log and documented by staff, in every shift, and to report if there’s any change on R1’s health and medical condition. R1 is schedule to be seen by his/her PCP.

LPA interviewed 2 staff (S1 and S2). S1 and S2 stated R1 has not had a change in condition and has not shown any signs confusion.

LPA requested staff schedule for the week ending 10/27 and R1's facility files such as but not limited to Physician’s report, Appraisal Needs and Services Plan and Medical Records.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/30/2023
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LPA requested and reviewed R1's Appraisal Needs and Services Plan LIC625 dated July 9, 2023. ADM stated did not update LIC625 after R1’s incident on 10/26/23. Although the facility implemented increase monitoring on R1 of every two hours and facility removed all cleaning solutions and other toxic materials from R1's apartment unit. Furthermore, ADM or Resident Services Director did not update LIC625. ADM stated that R1 will be seen by his/her PCP on 10/31/23. In addition, LPA interviewed staff who stated that every 2 hour checks is being done.

LPA interviewed Resident services director (RSD). RSD stated he/she was not able to update needs and services plan. RSD stated he/she did request R1's physician for an updated physicians report. RSD stated, R1 was given 2 hours status checks but the entire care plan itself was not updated.

Deficiency was cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.

This report was reviewed with Administrator Flavio Silva and a copy of the report was provided. Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/30/2023 02:41 PM - It Cannot Be Edited


Created By: Manuel Monter On 10/30/2023 at 11:41 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/31/2023
Section Cited
CCR
87463(a)

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(a) The pre-admission appraisal shall be updated... to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. This requirement was not met as evidence by:
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Licensee agrees to send plan of action in how the facility will ensure care and supervision are provided to residents whose conditions have changed or observations with updated care plans and submit the plan of action to CCL by POC date.
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Based on document review and investigation, R1 was not reassessed after R1 consumed cleaning solution on 10/26/23. R1’s Reappraisal was not updated for the facility to develop the care plan to meet resident’s needs. This poses an immediate risk to the health of the resident.
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023


LIC809 (FAS) - (06/04)
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