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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202714
Report Date: 04/04/2023
Date Signed: 04/04/2023 04:58:54 PM


Document Has Been Signed on 04/04/2023 04:58 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: 75DATE:
04/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Flavio SilvaTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator Flavio Silva. The purpose of the visit was to investigate an incident of suspected abuse that was reported to the Department.

During visit, LPA Marrufo interviewed residents R1-R7, staff S1-S5, and Administrator Flavio Silva. LPA Marrufo obtained copies of Physician's Report, Appraisal/Needs and Services Plan, and Emergency Contact forms for residents R1,R4, R5, and R7.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Administrator Flavio Silva and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2023
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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