435202714-9-4-2025-26-AS-RMAO-DMEKL3-20251013075917

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202714
Report Date: 09/04/2025
Date Signed: 09/04/2025 04:05:18 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
05/12/2025 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20250512094949

FACILITY NAME:	ATRIA EVERGREEN VALLEY		FACILITY NUMBER:	435202714
ADMINISTRATOR:	FELICIA R BARKLEY		FACILITY TYPE:	740
ADDRESS:	4463 SAN FELIPE ROAD		TELEPHONE:	(408) 532-7677
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95135
CAPACITY:	134	CENSUS: 87	DATE:	09/04/2025
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Shay Arias		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff unlawfully evicted a resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Business Director Shay Arias (BD).

On 05/12/2025, the Department received a complaint with the allegation that staff unlawfully evicted a resident.

On 05/13/2025, the Department conducted an initial investigation visit.

LPA interviewed previous Executive Director (PED) and previous Resident Service Director (PRSD).

LPA requested resident R1's physician report, appraisal needs and service plan , and R1's resident notes.

Continue on LIC9099-C. Page 1 of 4.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

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 4

Control Number 26-AS-20250512094949

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: 09/04/2025

NARRATIVE

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On 05/13/2025, LPA interviewed previous Executive Director (PED). PED stated resident R1's urologist notified local public health department regarding R1's Lab test result of an infection of resistant to broad spectrum antibiotics. PED stated local public health department asked if the facility has skilled nursing unit. PED stated the facility replied to public health department that the facility has no skilled nursing unit. PED stated public health department asked if the facility has Enhanced Barrier Protection, and the facility replied no. PED stated public health department stated R1 needed to sent to hospital if the facility had no skilled nursing unit and no Enhanced Barrier Protection. PED stated the facility contacted R1's family member (FM) to send R1 to hospital but FM stated he/she was unable to send R1 to hospital at that time. PED stated the facility called non emergency ambulance service and R1 was sent to hospital on 5/9/2025, around 8:00PM.

PED stated on 5/9/2025, around 11:30PM, R1 was discharged from hospital and was sent back to the facility. PED stated the facility told ambulance staff that the facility did not receive public health department's approval to accept R1. PED stated R1 was sent back to the hospital.

PED stated the facility explained to another family member of R1 that R1 needs to have a clearance of blood test and to notify public health department. PED stated the facility will accept R1 back to the facility when public health department notifies the facility that R1 is clear. PED stated the facility also explained to the hospital staff why the facility cannot accept R1 back to the facility. PED stated on 5/12/2025, Monday, around 11:00AM - 11:30AM, the facility confirmed with the hospital manger that he/she understood why the facility cannot accept R1 back to the facility at that time. PED stated the facility also explained to R1's family member (FM), POA, why the facility cannot accept R1 back to the facility at that time. PED stated until 5/13/2025, the facility did not receive any response from public health department.

LPA interviewed previous Resident Service Director (PRSD). PRSD stated resident R1's urologist notified the public health department regarding R1's lab test result. PRSD stated the facility received notice from public health department that R1 needs to be sent to hospital or to live in skilled nursing facility because the facility cannot provide the needed care service to R1. PRSD stated he/she consulted with Atria regional center office and they provided the advice to send R1 to hospital. S1 stated the facility contacted R1's family member (FM) but FM was unable to send R1 to hospital at that time. PRSD stated R1 was sent to hospital via ambulance on 5/9/2025 evening. PRSD stated after R1's treatment and clearance then R1 can return to the facility.
Continue on LIC9099-C. Page 2 of 4.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 26-AS-20250512094949

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: 09/04/2025

NARRATIVE

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PRSD stated he/she communicated with the hospital's case worker and the manager of the hospital why the facility cannot accept R1 back to the facility at that time. PRSD stated he/she also communicate with R1's family why the facility cannot accept R1 back to the facility at that time. PRSD stated on 5/13/2025, R1 still in the hospital.

On 8/6/2025, LPA interviewed Regional Vice President (RVP) Kris Waluszko. RVP stated he/she is aware of resident R1's case. RVP stated R1 lives in the facility assist living unit now. RVP provided R1's resident notes.

LPA interviewed staff S1. S1 stated R1 lives in the assist living unit now. S1 stated The hospital sent R1 to a skilled nursing facility. Then R1 was moved to another residential facility on 5/31/2025. S1 stated R1 returned to the facility on 6/25/2025. S1 stated R1 is fine in the facility now.

LPA interviewed R1's family member (FM), POA, in R1's room and R1 was on site in the room. FM stated R1 had UTI before and the Lab sent the test result to R1's urologist and public health department. FM stated on 5/9/2025, previous Resident Service Director (PRSD) notified him/her to send R1 to hospital. FM stated he/she was unable to send R1 to the hospital at that time. FM stated he/she asked the facility to call non emergency ambulance to send R1 to hospital. FM stated On 5/9/2025 night the hospital discharged R1 and sent R1 back to the facility. FM stated the facility did not accept R1 at that time and R1 was sent back to the hospital. FM stated R1 stayed at the hospital until 5/16/2025. FM stated on 5/16/2025, R1 was sent to a skilled nursing facility until 6/3/2025. FM stated R1 was moved a residential facility on 6/3/2025. FM stated R1 wanted to move back to the facility because R1's friends were here. FM stated R1 moved back to the facility on 6/25/2025. FM stated the facility explained to him/her why the facility was unable to accept R1 at that time.

FM was with LPA and R1, and called the hospital manager (HM). HM confirmed he/she understood R1's situation at that time. HM stated the facility explained to him/her why the facility cannot accept R1 at that time. HM stated the hospital did not recommend to send R1 to skilled nursing facility. HM stated the hospital sent R1 to skilled nursing home because no residential facility accepted R1 at that time.

Continue On LIC9099-C. Page 3 of 4.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20250512094949

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: 09/04/2025

NARRATIVE

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FM stated there might be a gap and confusion at that time. FM stated the LAB sent the test result to public health department but no one sent R1's clearance report to public health department until the skilled nursing facility sent it. FM stated R1 is fine at the facility now.

Based on the review of R1's resident note and the email log between public health department and previous resident service director (PRSD), public health department and the facility were discussing R1's test result and the status of R1.

The Department has investigated the above allegations. Based on the investigation, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citations noted at today’s compliant investigation visit. Exit interview conducted with BD. This report was provided to review and for signature. A copy of this report was provided to BD.

Page 4 of 4.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4