435202714-10-3-2024-26-AS-KHOS-DBMNFP-20241204092552

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202714
Report Date: 10/02/2024
Date Signed: 10/03/2024 12:02:34 AM

Unsubstantiated

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
04/23/2024 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20240423154553

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:	DATE:	10/02/2024
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Felicia Barkley - Exec Dir/Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facilty staff did not provide a resident a bathe for at least two months.
Faclity hired a private caregiver for a resident without resident's DPOA's consent.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced visit to deliver complaint findings. LPA Met with Executive Director/Administartor (ED/ADM) Felicia Barkley.

On 4/23/2024 - The department received a complaint alleging the facility staff did not provide a resident a bathe for at least two months and facility hired a private caregiver for a resident without the resident's DPOAs consent.

On 4/23/2024, LPA Partoza conducted an initial complaint investigation and requested for documents from the facility such as but not limited to physician's report and admission agreement. A complaint was filed on 2/15/2024 for the 2nd allegation complaint #26-AS-20240215155626.

page 1 of 2, See LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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 2

Control Number 26-AS-20240423154553

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: 10/02/2024

NARRATIVE

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Facility staff did not provide a resident a bathe for at least two months.
On 5/14/2024, RP sent a written statement stating that "the facility administration knowingly did not bathe R1 from January 10, 2024 through March 6, 2024."

Based on RP's written statement the Resident Services Director (RSD) specifically told his/her sibling that he/she was aware that R1 had not been bathed according to R1s level of care. Based on document review R1 refused to bathe for 8 weeks.

On 9/4/2024 and 9/20/2024 LPA interviewed staff 1 to 6 (S1 to S6). 6 Out of 6 staff stated that they cannot force a resident if they refuse to bathe. 6 Out of 6 stated that they will try and ask 3 times to convince resident to bathe.

Facility hired a private caregiver for a resident without resident's DPOA's consent.
On 4/24/2024, LPA interviewed ED/ADM who stated that the third party vendor "The Key" is the provider for the 1:1 care. The Key is a separate entity from the facility. ED/ADM stated on 10/2/2024 the facility refunded RP for the amount of $3,462.00 for the remaining balance.

On 4/28/2024, LPA interviewed responsible party (RP) and stated that former ED/ADM informed RP that R1 requires 1:1 care and have 24 hours to respond and make a decision. RP stated his/her sibling opted for the 1:1 care for R1 for one week and signed the electronic contract with "The Key" on 1/26/2024. RP stated they were able to speak with a representative from "The Key" and is able to change R1s care from 24/7 to 8 hrs a day. Based on review of RPs written statement, RP stated "I was able to obtain back $3,462 from the facility."

Based on review of the facility's admission agreement, "if residents become a safety risk to self and others during their residency, the facility have the right at their sole determination, at the resident's expense, private duty personnel to provide supervision or assistance...The facility will communicate the decision on behalf of the resident to the respective responsible party and will occur in advance, if reasonably possible..."

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are unsubstantiated.

No deficiencies were during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with executive director/administrator Felicia Barkley and a copy of the report was provided.

page 2 of 2 end of report

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC9099 (FAS) - (06/04)

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