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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202714
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:37:03 PM


Document Has Been Signed on 10/19/2023 04:37 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: 86DATE:
10/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Administrator, Flavio SilvaTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit. This case management visit was regarding an incident which occurred on 9/25/2023. LPA Rai met with Administrator (ADM) Flavio Silva and stated the purpose of the visit.

Per report, facility medication technician (S4) did not administer medication to resident (R1) resulting in missing a dose of medication prescribed by R1's physician. The R1's responsible party was contacted right away and R1's primary care physician was notified. Facility staff was advised to monitor R1 for any change of condition.

During today's visit, LPA Rai interview with ADM, who was notified by another staff member of the medication error and upon investigation it was discovered the medication error did occur based on electronic Medication Administration Record (eMAR) and ADM observed the missed dose still within the medication package. S4 was suspended and later terminated. ADM stated R1 was okay after the reported incident.

LPA Rai interviewed S1-S3. LPA Rai obtained a copy of S2-S3's most recent completed training course and resident roster.

ADM will email LPA Rai copy of S2-S4's training records and updated LIC 500.

This case management will be kept open pending investigation.

Exit interview conducted with Administrator (ADM) Flavio Silva and a copy of this report provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
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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