435202714-2-12-2024-26-AS-RMAO-D3LLHD-20240322084611

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202714
Report Date: 02/12/2024
Date Signed: 02/12/2024 05:06:17 PM

Unfounded

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
11/29/2023 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20231129142215

FACILITY NAME:	ATRIA EVERGREEN VALLEY		FACILITY NUMBER:	435202714
ADMINISTRATOR:	FLAVIO SILVA		FACILITY TYPE:	740
ADDRESS:	4463 SAN FELIPE ROAD		TELEPHONE:	(408) 532-7677
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	134	CENSUS: 79	DATE:	02/12/2024
		UNANNOUNCED	TIME BEGAN:	01:39 PM
MET WITH:	JR Garcia		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Staff did not resolve noise disturbance from another resident.

INVESTIGATION FINDINGS:

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Licensing Program (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Maintenance Director (MD) JR Gracia.

On 11/29/23, the Department received an allegation that the facility did not resolve a resident's concern regarding a noise from another resident's bedroom which prevent residented (referred to as R1) from resting and/or sleeping.

On 12/06/2023, the Department conducted an initial investigation visit. LPAs interviewed Executive Director/administrator (ED/ADM), 4 staff, and 2 residents. LPAs toured the 2nd floor and visited the resident apartments, and other possible sources of noise, like the activity area, and the medication

Continue on LIC9099-C. Page 1 of 2.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

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-20231129142215

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: 02/12/2024

NARRATIVE

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During the visit, LPAs interviewed Executive Director/Administrator (ED/ADM), residents (R1 and R2), and staff (S1 to S4). ED/ADM stated that R1 did complain about the loud TV volume coming from R2's bedroom.

ED/ADM stated R1's was complaint about R2's TV volume was addressed, a memo was sent to all residents stating the quiet time so everyone can rest, the memo states “To ensure that this environment is maintained, we request that all residents monitor the volume of their televisions and radios…TVs must be turned to lower volume around 10:00 p.m. or turned off around bedtime.”

In addition to the memo, ED/ADM installed acoustic panels on both sides of shared walls and suggested to R1 if he/she is willing to move to another apartment, but R1 refused. ED/ADM asked R2 to lower down the TV volume and made suggestions to R2 to use a headset. R2 refused to utilize a headset. ED/ADM asked R2’s if instead R2 is willing to move the TV to a different area in R2s apartment. R2 stated “yes.” ED/ADM instructed R1 to alert staff if R2's TV volume becomes loud during sleeping hours if needed.

Interviews with staff stated that after installation of the acoustic insulation panels on both walls, they could not hear noise from R2's bedroom but R1 continued to complain that a noise can still be heard from R2's apartment. Staff stated that none of the residents complained about loud TV noise from R2's bedroom.

Staff check on R2's bedroom when R1 alerts them about loud noise from R2's bedroom but when checked either R2 was not in his/her bedroom or TV was not in use, or volume level was at 20.

Based on observation and interviews, the facility made efforts to eliminate every possibility of noise reduction from R2's bedroom to R1's bedroom. No other residents complained of noise from R2's bedroom.

The Department has investigated the above allegations. Based on the interviews conducted with residents and staff, observations and documents reviewed, the allegations were UNFOUNDED. Meaning that the allegations were false, could not have happened and/or are without reasonable basis.

No deficiencies cited. This report was reviewed with MD and a copy of this report was provided MD.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

LIC9099 (FAS) - (06/04)

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