435202714-8-20-2026-26-AS-MPAA-DX5L93-20260820083248

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202714
Report Date: 08/19/2026
Date Signed: 08/20/2026 08:34:49 AM

Document Has Been Signed on 08/20/2026 08:34 AM - 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 VALLEY		FACILITY NUMBER:	435202714
ADMINISTRATOR/ DIRECTOR:	CHAVEZ, MADDALENA		FACILITY TYPE:	740
ADDRESS:	4463 SAN FELIPE ROAD		TELEPHONE:	(408) 532-7677
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY: 134		CENSUS: 99	DATE:	08/19/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Maddalena Chavez		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced required annual inspection and met with Executive Director/Administrator (ED/ADM) Maddalena Chavez to explain the purpose of the visit. The facility serves adults aged 60 and over. It is a three story building approved for 134 non-ambulatory residents and is equipped with delayed egress. The facility has an approved hospice waiver for 13 residents. LPA toured the interior of the facility, including the entryway, lobby, resident hallways, common areas, dining room, kitchen, laundry room, emergency food and water supply storage, medication room, activity areas, six Assisted Living (AL) resident rooms, and two private Memory Care (MC) rooms. Resident rooms and bathrooms were inspected. Emergency exits were observed free of obstruction and tripping hazards. The facility has a staffed reception lobby where visitors sign in and out. The main dining room, located on the ground floor, also serves as an activity area. Monthly activities for August were posted conspicuously throughout the building, including hallways, the dining area, and the elevator. Residents in AL received individual copies of the monthly calendar. LPA observed resident participation in activities during the visit in both AL and MC areas. The MC unit is equipped with delayed egress doors and functioning audible alarms. In the MC dining area, LPA observed that no utensils were left on tables, and all dining utensils were stored in a locked cabinet.

Romeo Manzano
Maria Partoza
	DATE: 08/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 08/19/2026

NARRATIVE

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The facility kitchen is equipped with commercial-grade walk-in refrigerator and freezer. Kitchen doors remained locked when not in use and were not accessible to residents. LPA observed sufficient emergency drinking water, a seven day supply of non-perishable food, and easy-to-prepare emergency meals. Snack stations were available in activity areas. The kitchen was found sanitary and organized. The freezer contained sufficient perishable food for at least two days. The refrigerator temperature was measured at 38°F and the freezer at 0°F. The dishwashing area and kitchen hot water were measured above 125°F, and required warning signage was posted. Kitchen staff were observed cleaning and preparing the area for the next meal. Dining room floors were clean, and residents were present during inspection.

During inspection of MC and AL resident rooms, LPA observed storage for resident's personal-belonging that is sufficient and within the regulation requirement. Hot water temperatures measured using a digital thermometer ranged between 108.8°F and 115.1°F.

LPA reviewed 10 staff files for background clearance, required training, personnel documentation, and current certifications. Ten resident files were reviewed for individual care plans, physician reports (LIC 602), personal rights documentation, admission agreements, emergency information, and consent forms.

Medication records and the medication room were reviewed and records are current. The Resident Services Supervisor (RSS) stated medication audit procedures occur three times daily—one per shift.
LPA verified that the facility conducts required training per Health and Safety Code (HSC) 1569.626. Fire and disaster drills are completed monthly across different shifts. Disaster drills occurred on 01/13/26, 02/19/26, 03/10/26, 04/07/26, 05/19/26, 06/23/26, and 07/21/26.

Annual inspection of the fire alarm system is conducted by Johnson Controls, covering the entire building including stairwells, resident rooms, exterior areas, kitchen, and all floors. Fire extinguishers are placed strategically on each floor and inspected monthly. The facility maintains a fire alarm panel connected to local fire services, a manual wet standpipe, and operational sprinkler systems.

No deficiencies were cited during today’s annual required inspection. An exit interview was conducted with Executive Director/Administrator (ED/ADM) Maddalena Chavez. A copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2026

LIC809 (FAS) - (06/04)

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