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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202775
Report Date: 12/28/2022
Date Signed: 12/28/2022 12:38:38 PM


Document Has Been Signed on 12/28/2022 12:38 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 ALMADENFACILITY NUMBER:
435202775
ADMINISTRATOR:KRIS WALUSZKOFACILITY TYPE:
740
ADDRESS:4610 ALMADEN EXPRESSWAYTELEPHONE:
6692584567
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:240CENSUS: 120DATE:
12/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Hunter Obrero, Assistant Executive DirectorTIME COMPLETED:
12:45 PM
NARRATIVE
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On 12/28/2022 at 8:50am, Licensing Program Analyst (LPA) Simi Rai conducted an unannounced annual required inspection and met with Assistant Executive Director (AED), Hunter Obrero.

During visit, LPA Rai toured the 4 levels of the facility, including the multiple common areas, 3 bedrooms on each level, 3 bathrooms on each level. All fire exit routes were free and clear of obstruction. All staff observed wearing a face covering.

Facility has a designated entry point for sign-in, symptom screening, temperature check for all visitors and staff. Per updated visitation guidelines in PIN 22-28.1-ASC, visitors are allowed in the community without the proof of a negative COVID-19 test or proof of COVID-19 vaccination status. Hand sanitizer made available at entry and throughout the facility.

Visitation guidelines posted at the entrance. Bathrooms supplied with hygiene products and paper supplies. AED will post up hand washing signs in bathroom and near kitchen sinks.

Facility has procedures to isolation and testing for COVID-19. Staff are trained on infection control. Staff are N95 fit tested. Facility staff clean and disinfect multiple times daily and as needed. The following posters observed to include wash your hands and wear a face mask.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022
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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Document Has Been Signed on 12/28/2022 12:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 ALMADEN
FACILITY NUMBER: 435202775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance (e) All invididuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, Facility failed to ensure 3 out of 3 staff members (S1-S3) associated to the facility which is an immediate safety risk to the residents in care. LPA observed S1-S3 are fingerprint cleared but not associated to the facility.
POC Due Date: 12/28/2022
Plan of Correction
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Assistant Executive Director correcred deficiency during today's visit. LPA was provided the Background Clearance letter assosciated with the facility for S1-S2.
LPA observed Assistant Executive Director completing the LIC 9182 and faxing a copy to CCL for S3.
*** A civil penalty of $1500.00 is being assessed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2022
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 ALMADEN
FACILITY NUMBER: 435202775
VISIT DATE: 12/28/2022
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On 12/28/2022 at 10:34am LPAs observed S1-S3 fingerprint clearance but not associated to the facility. AED completed fingerprint transfer request for S1-S3 and Background Clearance Letter was provided for S1-S2 effective 12/28/2022 at 10:50am. LPAs observed Assistant Executive Director completing the LIC 9182 and faxing a copy to CCL for S3 effective 12/28/2022 at 12:29pm.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.

A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500), for staff (S1) working at the facility without association. A second civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500), for staff (S2) working at the facility without association. A third civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500), for staff (S3) working at the facility without association. Please see LIC 421BG.

Technical Assistance Notes were provided.

This report was reviewed with Assistant Executive Director, Hunter Obrero. A copy of the report and Appeal Rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022
LIC809 (FAS) - (06/04)
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