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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202714
Report Date: 12/14/2022
Date Signed: 12/14/2022 01:04:13 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
03/09/2022 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20220309144304
FACILITY NAME:ATRIA EVERGREEN VALLEYFACILITY NUMBER:
435202714
ADMINISTRATOR:JASON WALTHOURFACILITY TYPE:
740
ADDRESS:4463 SAN FELIPE ROADTELEPHONE:
(408) 532-7677
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:134CENSUS: 71DATE:
12/14/2022
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Flavio SilvaTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Facility did not meet resident's hygiene needs
Facility did not communicate promptly with family member
Resident’s room not large enough to allow for easy passage and comfortable usage of bed and other furniture
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the findings of the above allegations. LPA met with Executive Director (ED), Flavio Silva.

On 03/09/2022, the Department received a complaint regarding the above allegations. On 03/16/2022, LPA Marybeth Donovan opened the initial complaint investigation. From 09/14/2022 - 12/14/2022, LPA Dolores continued the complaint investigation.

From 03/16/2022 – 12/14/2022, the following documents were obtained to include the facility resident roster, staff roster, facility room sketches, R1 – R4’s files to include the admission agreements, billing statements, physician’s reports, needs and services plan, and communication notes. From 03/16/2022 - 12/14/2022, a total of 4 staff were interviewed.

PAGE 1 OF 3.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
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 9
Control Number 26-AS-20220309144304
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/14/2022
NARRATIVE
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Facility did not meet resident’s hygiene needs
In June 2021, resident (R1) was brought to a nail salon where it was found R1 had multiple hard dark matter and yellow gunk underneath the fingernails.

Based on observation of the photograph provided from R1’s visit to the nail salon in June 2021, the photograph showed the yellow and black gunk/hard matter that was removed from underneath R1’s fingernails.

Based on record review, R1’s services plan dated April 19, 2021 states the service of bathing/showering seven times per week and grooming two times a day. R1’s physician report states the need of assistance in bathing and toileting.

The facility did not ensure to meet R1’s hygiene needs despite the service of daily bathing/showering from the observation of the build-up of yellow and black gunk underneath R1’s fingernails.

Facility did not communicate properly with family member
In January 2021, the facility had a COVID-19 outbreak resulting in multiple residents and staff contracting COVID-19. R1 was part of the group of residents who contracted COVID-19 and recovered.

During a care conference in August 2021, R1’s responsible person(s) was informed R1 had not received the COVID-19 vaccination after recovery from COVID-19 in January 2021. Based on record review, R1’s records did not state the responsible person(s) was notified or received a follow-up that R1 had not yet received the COVID-19 vaccine after recovery.

Resident’s room not large enough to allow for easy passage and comfortable usage of bed and other furniture
In January 2021, R1 was relocated to a shared room in memory care. R1 used a wheelchair and hospital bed.

Page 2 of 3.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 26-AS-20220309144304
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/21/2022
Section Cited
CCR
87464(f)(4)
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(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement was not met as evidenced by:
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Licensee will provide an in-service training to all staff on proper hygiene. Licensee will submit the in-servce training record to LPA Dolores by POC due date.
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Based on interview, observation, and record review the facility did not ensure resident (R1)’s hygiene needs were met despite the daily service for bathing/showering from the observation of the build-up of gunk underneath R1’s fingernails which poses a potential health, safety, and personal rights risk to persons in care.
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Type B
12/21/2022
Section Cited
CCR
87468.1(a)(8)
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met as evidenced by:
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Licensee will send to the Department their procedures and policies regarding communication and follow-ups with family regarding the residents clinical events in the community. Licensee will send the POC via email to LPA by POC due date.
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Based on interview and record review, the facility did not ensure to follow-up with R1’s responsible person(s) on the COVID-19 vaccination which poses a potential health, safety, and personal rights risk to persons in care.
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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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
03/09/2022 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20220309144304

FACILITY NAME:ATRIA EVERGREEN VALLEYFACILITY NUMBER:
435202714
ADMINISTRATOR:JASON WALTHOURFACILITY TYPE:
740
ADDRESS:4463 SAN FELIPE ROADTELEPHONE:
(408) 532-7677
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:134CENSUS: DATE:
12/14/2022
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Flavio SilvaTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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2
3
4
5
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9
Facility not following COVID 19 guidance or protocol
Resident's room was not in good repair
Facility did not follow resident's Admission Agreement
Staff did not know how to operate hospital bed

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the findings of the above allegations. LPA met with Executive Director (ED), Flavio Silva.

On 03/09/2022, the Department received a complaint regarding the above allegations. On 03/16/2022, LPA Marybeth Donovan opened the initial complaint investigation. On 09/14/2022, LPA Dolores continued the complaint investigation.

From 03/16/2022 – 12/14/2022, the following documents were obtained to include the facility resident roster, staff roster, facility room sketches, R1 – R4’s files to include the admission agreements, billing statements, physician’s reports, needs and services plan, and communication notes. From 03/16/2022 - 12/14/2022, a total of 4 staff were interviewed.

Page 1 of 4.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 26-AS-20220309144304
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/14/2022
NARRATIVE
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Facility not following COVID 19 guidance or protocol
In January 2021, the facility had a COVID-19 outbreak resulting in multiple residents and staff contracting COVID-19. Resident (R1) was part of the group of residents who contracted COVID-19.

On 03/16/2022, LPA Donovan interviewed 3 out of 3 staff members (S1 – S3). Based on interviews, the facility follows COVID-19 guidance and protocols by implementing daily COVID-19 symptom screening for staff and residents, deep cleaning, disinfecting, encouraging social distancing, and encouraging residents to wear a mask during an outbreak.

Based on record review, R1’s responsible party signed and acknowledged the facility’s COVID-19 Disclosure for potential exposure, which was part of the admission agreement. The COVID-19 Disclosure for potential exposure states the possibility of residents or staff residing or working at the facility who may be infected with COVID-19 and despite precautions the risk of exposure to COVID-19 cannot be completely eliminated due to the methods and rate of transmission of the virus.

The facility reported the COVID-19 outbreak to the Department and was in contact with the Department during the outbreak. The Department did not note any issues or concerns during the outbreak.

In March 2021, R1 sustained an unwitnessed fall. R1’s responsible party was notified, but due to the pandemic, R1 was not sent to the hospital. Based on record review, R1 was able to get back up with assistance and had no complaints or discomfort. R1 was assessed by staff and monitored for 72 hours. There was no observation of apparent pain, discomfort, injuries, and bruises.

Resident’s room was not in good repair
It was alleged that R1’s bedroom was not in good repair by containing a small oval hole on the exterior side of the bathroom door, chipped paint on the walls, and the bathroom molding to be in disrepair.

Page 2 of 4.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 26-AS-20220309144304
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/14/2022
NARRATIVE
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On 03/16/2022, LPA Donovan inspected the bedroom under investigation. The bedroom was vacant during visit. No immediate issues or concerns were noted.

On 09/14/2022, LPA Dolores observed the bedroom under investigation to be vacant. LPA observed the hole on the exterior side of the bathroom door in the bedroom had not yet been repaired. The hole did not penetrate to the interior side of the door and LPA did not observe the hole to be see through. The paint inside the bedroom was not observed chipped and bathroom molding was observed to be in good repair. LPA observed the bathroom was clean and sanitary.

Facility did not follow resident’s Admission Agreement
R1 was admitted to the facility in October 2020. In January 2021, R1 was relocated from Assisted Living to Memory Care. Based on record review, R1’s responsible party signed and dated the relocation form from assisted living to memory care.

In April 2021, R1 had an increase in services for continence and bathing/showering. One of the two services were requested by R1’s responsible person(s) to increase a service from one to seven days a week. One of the two services were increased based upon a routine assessment. Due to the increase in services, there was an increase of cost per month.

Based on record review, facility staff attempted to contact R1’s responsible person(s) multiple times to review and sign R1’s updated routine assessment. After multiple attempts, facility staff was able to review R1’s updated assessment with the responsible person(s). A few weeks later, R1’s responsible person(s) signed the updated assessment reflecting the requested additional increase in service.

R1’s signed residency agreement states a change in the level of care will be effective immediately and the responsible person(s) will be notified of the change within 2 business days. If a resident has a change in level of care, the facility will send the responsible person(s) the new assessment by email or inform the responsible person(s) verbally.

Page 3 of 4.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 26-AS-20220309144304
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/14/2022
NARRATIVE
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Staff did not know how to operate hospital bed
In March 2021, resident (R1) sustained an unwitnessed fall. Based on record review, R1 did not sustain any injuries or bruises and did not complain of pain and discomfort. R1 was not transported for medical treatment due to the pandemic. Its alleged staff did not know how to operate a hospital bed which may have resulted in the fall.

On 09/14/2022, LPA Dolores observed a staff member demonstrate how to operate 2 hospital beds. Staff member was able to demonstrate how to operate the hospital bed to include positioning the bed and adjusting the side rails. Staff member states to be the person to train new hires on how to operate the hospital bed. Staff has procedures for when there are technical difficulties in operating the hospital bed.

The Department has investigated the above allegations. Based on interviews, observation, and record review the Department has determined that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Flavio Silva and a copy of the report was provided.

Page 4 of 4.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 26-AS-20220309144304
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/14/2022
NARRATIVE
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On 03/16/2022, LPA Donovan inspected 5 bedrooms in memory care. According to the staff interview, the room under investigation was a shared room with proper furniture to include two single beds, two dressers, and a folding chair.

On 09/14/2022, LPA Dolores inspected 8 bedrooms in memory care. It was observed the bedroom under investigation has a different layout compared to the other bedrooms, due to the bedroom being located in the corner of the facility.

On 12/14/2022, LPA, ED, and the Memory Care Director (MCD) measured a hospital bed, wheelchair, and the section of the bedroom where R1’s hospital bed was placed. LPA not observed enough space to maneuver a wheelchair to the bedroom's exit. LPA, ED, and MCD observed the length of a hospital bed being too long which did not allow for easy passageway to the exit with a wheelchair.

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

Deficiencies are being cited per California Code of Regulations, Title 22. A plan of correction was developed with the Executive Director. This report was reviewed with Executive Director, Flavio Silva and a copy of the report and appeal rights were provided.

Page 3 of 3.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 26-AS-20220309144304
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2022
Section Cited
CCR
87307(a)(2)(A)
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(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (A) Bedrooms shall be large enough to allow for easy passage between and comfortable usage of beds and other required items of furniture specified below, and any resident assistant devices such as wheelchairs or walkers. This requirement was not met as evidenced by:
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Licensee will ensure to arrange all the bedrooms appropriately to allow for easy passageway. Licensee will send a statement of understanding to LPA via email by POC due date.
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Based on observation, the licensee did not ensure R1’s room allowed for easy passageway to the bedroom's exit with a wheelchair which poses an immediate health, safety, and personal rights risk to persons in care.
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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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC9099 (FAS) - (06/04)
Page: 9 of 9