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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202714
Report Date: 05/30/2025
Date Signed: 05/30/2025 04:10:32 PM

Unfounded


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
04/13/2023 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20230413113300
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:
05/30/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Felicia BarkleyTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility took medications away from a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Felicia Barkley, Administrator (ADM). On 04/13/2023, the department received a complaint with the above allegation. On 04/19/2023, LPA David Marrufo conducted an initial complaint investigation visit. On 09/04/2024, LPA Mita Partoza conducted an additional complaint investigation visit.

On 04/12/2023, the facility submitted two Unusual Injury/Incident Reports (IRs) to the department. The IRs reported an incident involving two residents, resident R1 and resident R2. The incident occurred on 04/12/2023. The IRs state that a facility staff found a pill of medication M1 in R2’s living unit. The IRs state that R2 told the staff that R2 had a headache and R1 gave two pills of M1 to R2. R2 stated to have consumed one of the pills. Facility staff confiscated the other pill of M1. The IRs state that R1 stated that R2 complained of a headache and R1 gave R2 two tablets of M1. See LIC9099-C page for more information. Page 1 of 2.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
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 7
Control Number 26-AS-20230413113300
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: 05/30/2025
NARRATIVE
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LPA Marrufo obtained a copy of R1’s Physician’s Report, dated 07/12/2022. R1’s Physician’s Report states R1 is not able to administer own prescription medications, not able to administer own PRN medications, and not able to store own medications.

LPA Marrufo obtained a copy of R2’s Physician’s Report, dated 07/05/2022. R2’s Physician’s Report states R2 is not able to administer own prescription medications and is able to administer own PRN medications. R2’s Physician’s Report states R2 is not able to store own medications. There is a handwritten note stating, “please manage prescription medication. PRN medications – OK with patient.”

During interview on 04/19/2023, R1 stated to have given R2 a tablet of M1. R1 stated that R2 visited R1 in R1’s living unit and gave R2 a tablet of M1 from a bottle that R1 had stored in one of R1’s cabinets. R1 stated to have had the bottle of M1 since August but does not remember how he/she got the bottle.

During interview on 04/19/2023, staff S1 stated to have observed a pill of M1 in R2’s sink. S1 stated R2 stated to S1 that R1 gave R2 two pills of M1, and R2 had already consumed one of the pills of M1 and was waiting 8 hours to consume the other pill of M1. S1 stated to have visited R1 to see if R1 had any more medications. S1 stated R1 gave S1 the bottle of M1 and more medications in a zip lock bag. S1 stated the bottle of M1 did not have a prescription label. S1 stated that M1 is listed as a PRN in R1’s Medication Administration Record (MAR).

LPA Marrufo obtained a copy of R1’s MAR, which lists M1 as a PRN.

This agency has investigated the complaint allegation listed. Based on interviews, and review of records, the CCLD has found that the complaint allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

This report was reviewed with Life Guidance DIrector Beth Jennings and a copy of this report was provided.

Page 2 of 2.
END REPORT
SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
04/13/2023 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20230413113300

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:
05/30/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Felicia BarkleyTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Lack of supervision resulted in resident providing medication to another resident
INVESTIGATION FINDINGS:
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LPA Marrufo obtained a copy of R1’s Physician’s Report, dated 07/12/2022. R1’s Physician’s Report states R1 is not able to administer own prescription medications, not able to administer own PRN medications, and not able to store own medications.

During interview on 04/19/2023, R1 stated to have given R2 a tablet of M1. R1 stated that R2 visited R1 in R1’s living unit and gave R2 a tablet of M1 from a bottle that R1 had stored in one of R1’s cabinets. R1 stated to have had the bottle of M1 since August but does not remember how he/she got the bottle.

During interview on 04/19/2023, staff S1 stated to have observed a pill of M1 in R2’s sink. S1 stated R2 stated to S1 that R1 gave R2 two pills of M1, and R2 had already consumed one of the pills of M1 and was waiting 8 hours to consume the other pill of M1. S1 stated to have visited R1 to see if R1 had any more medications. See LIC9099-C page for more information. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 26-AS-20230413113300
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: 05/30/2025
NARRATIVE
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S1 stated R1 gave S1 the bottle of M1 and more medications in a zip lock bag. S1 stated the bottle of M1 did not have a prescription label. S1 stated that M1 is listed as a PRN in R1’s Medication Administration Record (MAR).

Based on records review and interviews, there is preponderance of evidence to prove the alleged violations did occur. Therefore, the allegation is substantiated.

See 9099-D for a deficiency cited per the California Code of Regulations, Title 22. This report was reviewed with Life Guidance Director Beth Jennings and a copy of this report and appeal rights were provided.


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END REPORT
SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Citations on this Visit Report are Under Appeal!

Control Number 26-AS-20230413113300
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
05/31/2025
Section Cited
CCR
87465(h)(1)(B)
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87465 Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances:
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Licensee agrees to submit a Plan of Correction by PoC due date to the department stating how the licensee agrees to conduct an in-service training with staff on ensuring that medications are
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(B) Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed. This requirement was not met as evidenced by: Licensee did not ensure that medications that were determined by the physician to be hazardous if kept in R1’s personal possession were centrally stored and not in the possession of R1 in R1’s living unit, which poses an immediate safety risk to residents in care.
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centrally stored, including by inspecting resident living units for unsecured medications. Once training is complete, the licensee will submit copies of training logs with names of staff trained, dates of training, training topics, and names and qualifications of trainers.
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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.
SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
04/13/2023 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20230413113300

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:
05/30/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Felicia BarkleyTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility mishandled resident’s personal belongings
INVESTIGATION FINDINGS:
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During interview on 04/19/2023, R1 stated to be missing personal belongings after transferring to the facility. R1 stated to have come from an Atria facility in Puerto Rico, but did not recall how or when R1 arrived at the facility.

On 04/19/2023, LPA Marrufo made two attempted telephone calls to R1’s Family Member FM1, who is listed as the emergency contact for R1. However, the phone number did not work. LPA Marrufo made an attempted telephone call to FM1 on 05/30/2025 but was not able to reach FM1.

During visit on 05/30/2025, LPA Marrufo reviewed R1’s facility file, which did not contain a Safeguard for Property and Valuables form.

See LIC9099-C page for more information. Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 26-AS-20230413113300
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: 05/30/2025
NARRATIVE
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During visit, ADM stated that the licensee does not have any facilities in Puerto Rico.

Based on information from interviews conducted with staff, and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated.

No Deficiencies were cited under California Code of Regulations Title 22.

This report was reviewed with Life Guidance Director Beth Jennings and a copy of this report was provided.



Page 2 of 2.



END REPORT
SUPERVISORS NAME: Maria Partoza
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7