435202714-10-20-2021-26-AS-KHOS-C8LS9D-20211109124034

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202714
Report Date: 10/15/2021
Date Signed: 10/20/2021 02:47:36 PM

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
02/11/2021 and conducted by Evaluator Anna Bui

COMPLAINT CONTROL NUMBER: 26-AS-20210211104217

FACILITY NAME:	ATRIA EVERGREEN VALLEY		FACILITY NUMBER:	435202714
ADMINISTRATOR:	CABUENA, JAIRUS		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:	10/15/2021
		UNANNOUNCED	TIME BEGAN:	12:31 PM
MET WITH:	Kris Waluszko		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Resident injured herself while in care.

INVESTIGATION FINDINGS:

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On 10/15/2021 at 12: 31 pm, Licensing Program Analyst (LPA) Anna Bui conducted an unannounced complaint investigation visit to deliver the finding to the above allegation. LPA met with Kris Waluszko, Interim-Executive Director.

On 02/02/2021, the Department conducted an initial 10-day complaint investigation visit to the above allegation.

Between 02/02/2021 and 08/24/2021, interviews were conducted with 4 staff and R1’s personal companion. 4 out of 4 staff stated they were not aware of R1’s depression and suicidal ideations. 4 out of 4 stated R1 did not show signs of depression or anything out of the ordinary prior to the incident. R1’s personal companion was hired after the incident but was made aware of R1’s incident.

Unsubstantiated

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: 10/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20210211104217

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: 10/15/2021

NARRATIVE

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Facility records did not show any documentation of R1’s history of depression or suicidal ideations. R1’s medical records indicated that R1 was not on anti-depressant medication. Police report, coroner’s report, and death certificate were also reviewed. Police report noted the interview of R1 stating R1 no longer wish to live and a suicide note written by R1 was confiscated by the police officer on scene.

Documents and interviews suggest that facility staff were unaware of R1’s depression and suicidal ideations. The facility did not have medical records that documented R1’s prior suicide attempt. Once aware of R1’s depression and suicidal tendencies, R1’s room was searched for unsafe items. The facility hired a personal companion to stay with R1 24 hours a day when R1 returned to the facility.

The Department has investigated the above allegation. Based on interviews and records reviewed, the Department found the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

No deficiencies were cited during today’s visit.

This report was reviewed with Kris Waluszko, Interim-Executive Director, and a copy was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Anna Bui	TELEPHONE: 650-269-7419
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

LIC9099 (FAS) - (06/04)

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