435202714-12-22-2025-26-AS-RMAO-DQQSNN-20260127130150

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202714
Report Date: 12/22/2025
Date Signed: 12/22/2025 04:56:45 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
09/05/2025 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20250905092711

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: 80	DATE:	12/22/2025
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Maddalena Chavez		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Facility Administrator is not consistently present to supervise and direct the facility's daily operations.
Facility staff did not have direct supervision for 3 months causing delays in medication administration.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced visit to deliver the findings of the complaint investigation. LPA met with Executive Director/Administrator Maddalena Chavez and stated the purpose of the visit.

On 09/05/25, the Department received a complaint with the above allegations. On 09/11/25, 09/18/25, and 10/07/25, the Department continued with the investigation, conducted interviews and observations.

LPA conducted a phone interview with Witness 1 (W1), who stated that the facility does not have an administrator, at least 80% of the time. W1stated that he/she met the Regional Vice President (RVP); however, RVP is not at the facility every day and staff did not have direct supervision for 3 months when the facility administrator and Resident Service Director (RSD) left early July of 2025. W1 stated that R1 was given a medication that belongs to another resident. W1 stated that the trainee no longer works at the facility after the incident. Page 1 of 4 see LIC 9099C

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025

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-20250905092711

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: 12/22/2025

NARRATIVE

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LPA interviewed the Regional Vice President/Administrator (RVP/ADM), stated that former ED/ADM and RSD resigned, RVP took over the daily operation of the facility the day after ADM vacated the position. RVP stated there was no gap of supervision for 3 months. When RVP is attending to other duties and responsibilities, he/she assigns directors and managers to supervise and manage facility operation. LPA observed RVP to be present at the facility during unannounced investigation visits on 09/05/25, 09/11/25, 09/18/25 and 10/07/25. LPA observed that a manager of the day is posted at the front desk.

LPA interviewed 8 staff (S2 to S9). 8 out 8 staff stated that RVP/ADM is at the facility 3 to 5 days in a week and comes in at random times, in addition 8 out of 8 staff stated an interim RSD was assigned and an RSS was hired to fill in the position expeditiously. 8 out of 8 staff stated there was no gap for 3 months that staff were not supervised.

This agency has investigated the complaint allegations that facility Administrator is not consistently present to supervise and direct the facility's daily operations and facility staff did not have direct supervision for 3 months causing delays in medication administration. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

No deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with Executive Director/ Administrator (ED/ADM) Maddalena Chavez. A copy of the report was provided.

page 2 of 4

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
09/05/2025 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20250905092711

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: 80	DATE:	12/22/2025
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Maddalena Chavez		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Facility staff did not administer resident's medication correctly due to lack of supervision while in training.

INVESTIGATION FINDINGS:

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Continuation of LIC 9099

On 09/18/25 LPA conducted an interview with 5 residents (R1 to R5). R1, R2 and R5 stated they have not missed any medication and are not aware of any missed medication and stated staff were on time in passing their medication. R3 and R4 declined to be interviewed.

LPA reviewed R1s Centrally Stored Medication and Destruction Record (CSMDR) and the Medication Administration Record (MAR) for the months of February 2025, March 2025 and April 2025, and did not observe a missed medication.

page 3 of 4
See LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025

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 4

Control Number 26-AS-20250905092711

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: 12/22/2025

NARRATIVE

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According to responsible party (RP), R1s medication was put on hold on 03/22/25 when the medication technician (MT1) trainee inadvertently administered the incorrect medication. A senior medication technician (MT2) was with MT1 while in training. R1 was observed for 24 hours for possible adverse reaction. MT2 reported the incident to R1s medical team, and responsible party (RP), former ADM, RSD and CCLD expeditiously according to the policy and procedure of the facility. RP stated that there was no adverse effect on R1, and the error was correctly handled.

Based on document review and interviews that facility staff did not administer resident’s medication correctly due to lack of supervision while in training may have happened or is valid, there is not a preponderance of evidence to prove the allegation did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with Executive Director/Administrator (ED/ADM) Maddalena Chavez and a copy of the report was provided.

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end of report

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4