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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202714
Report Date: 07/28/2021
Date Signed: 07/29/2021 01:17:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 VALLEYFACILITY NUMBER:
435202714
ADMINISTRATOR:ANDRES ANAYAFACILITY TYPE:
740
ADDRESS:4463 SAN FELIPE ROADTELEPHONE:
(408) 532-7677
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:134CENSUS: 80DATE:
07/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Edith Luiz / Diane MartinezTIME COMPLETED:
04:05 PM
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On 07/28/2021 at 2:16 pm, Licensing Program Analyst (LPA) Anna Bui conducted an unannounced Annual Required 1 Year visit. LPA met with Edith Luiz, Culinary Director. Diane Martinez, Resident Services Director, joined LPA at the end of the tour.

LPA toured the facility beginning with the main entrance. The entrance had a thermometer, hand sanitizer, and sign-in log to document temperature and screening questions. There was a sign-in log for visitors and residents returning back from an outing. Universal precautions and COVID-19 protocols were posted throughout the facility. Restrooms had hand soap and paper towels readily available. Hand washing sign was posted at all hand washing stations.

Staff were observed wearing a mask and following COVID-19 protocols. Facility observed to have adequate supply of PPE.

No deficiencies were cited during today's visit.

This report was reviewed with Diane Martinez, Resident Services Director, and a copy was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna BuiTELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
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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