435202714-4-8-2026-26-AS-RMAO-DTKN39-20260428100558

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202714
Report Date: 04/08/2026
Date Signed: 04/08/2026 05:01:43 PM

Substantiated

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
01/21/2026 and conducted by Evaluator Maria Partoza

COMPLAINT CONTROL NUMBER: 26-AS-20260121163506

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: 88	DATE:	04/08/2026
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Maddalena Chavez		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Facility calling 9-1-1 for a lift assistance even if there is no need for emergency services

INVESTIGATION FINDINGS:

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

On 01/21/2026, the Department received a complaint alleging the facility contacted 911 multiple times per day for lift assists that did not constitute medical emergencies. LPA conducted interviews with the reporting party, witnesses, staff, residents, and reviewed the facility’s 911 call logs and incident reports for the period of 08/01/2025 up to 01/31/2026.

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Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20260121163506

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: 04/08/2026

NARRATIVE

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Witnesses 1 and 2 (W1 and W2) from the local emergency response agencies reported receiving calls from the facility that did not meet medical emergency criteria, including multiple calls per day during early January. One witness stated residents were left on the floor for responders to lift, and that these calls were categorized as public service rather than medical emergencies.

On 01/23/2026 at approximately 1:35 p.m., LPA Partoza received a phone call from Executive Director/Administrator (S1) regarding the above allegation. During the phone conversation LPA inquired if S1 is aware of the Provider Information Notification (PIN) 25-06-ASC. S1 stated that he/she is unaware of the PIN. LPA proceeded to read PIN 25-06-ASC to S1 and discussed the PIN with S1. LPA provided technical assistance to S1 with accessing the CCLD website PIN portal.

LPA interviewed the following staff (S1 to S8) on the following dates, 01/23/2026, 02/06/26, 02/27/2026 and 03/26/2026.

S1 to S8 stated that the facility is non-medical, has no 24/7 nurse, and does not maintain lift equipment. S1 to S8 stated, staff provide one person assistance and are not authorized or trained to take vital signs. Staff S1, S3 to S7 stated that staff calls 911 for unwitnessed falls, head strikes, new pain, and when residents were unable to bear weight or assist with transfers. Staff S1, S3 to S8 stated that 911 was contacted for lift assistance in non-injury situations due to size, weight or gender disparities between staff and residents and the absence of lift equipment. S1 to S8 stated that the facility does not have lift equipment and provides one person assistance.

On 02/27/2026, LPA Partoza interviewed four residents (R1–R4). R1 and R4 declined to be interviewed. R2 and R3 stated they required lift assistance in the past and could not be lifted by staff. R3 stated he/she began using personal lift equipment to avoid 911 calls.

Based on the documents reviewed, eleven 911 calls were made between 01/04/2026 and 01/31/2026. On 01/10/2026, two calls were made, one of the calls had no corresponding documentation. On 01/11/2026, two calls were made for two residents, followed by a third call on 01/12/2026 for one of the residents at the physician’s request.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20260121163506

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: 04/08/2026

NARRATIVE

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On 12/27/2025, two calls were made to 911 and both residents were transported to the emergency room. Additional documented 911 calls identified as lift assists occurred on 08/09/2025, 10/31/2025, 11/15/2025, and 12/23/2025, that was documented by staff on the incident report as unwitnessed falls and residents had no injury, declined hospital transport, or were unable to stand without assistance.

Based on the Provider’s Information Notification (PIN) 25-06-ASC issued on 06/24/2025, it states, “For circumstances that do not constitute an imminent threat, as outlined in California Code of Regulations (CCR) Title 22, Section 87465 (g), Incidental Medical and Dental Care Services, as a best practice, licensees may consider alternative options for obtaining medical attention. Evaluation by an on site appropriately skilled professional or other licensed healthcare professional, Program of All-inclusive Care for the Elderly (PACE) provider, hospice care to name a few (pg. 2). “Lift Assists” occurs when a resident needs help with mobility or transferring from one position to another, but there are no signs of injury or medical concern. Licensees are responsible for ensuring that sufficient staff are available to meet resident’s needs and staff are adequately trained and equipped to assist residents with lift assistance, mobility and transfers safely, and without the need for emergency services, as long as the resident is not injured or experiencing health concerns…Thus, calling 911 solely for lift assist is not appropriate if it has been determined that the resident has not sustained any injury (pg. 4).”

Based on document review and interviews, the facility contacted 911 for lift assistance in non emergency situations on the following dates 08/09/2025, 10/31/2025, 11/15/2025, and 12/23/2025. Staff reported that 911 was contacted when residents could not assist with transfers due to the absence of lift equipment and the facility’s one person assist staffing. PIN 25-06-ASC (06/24/2025) states that 911 should not be contacted solely for lift assist when no injury is present and that licensees are responsible for ensuring staff are trained and equipped to perform non-injury lift assists.

Based on LPAs observations, interviews which conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22 87465 (g) is being cited on the attached LIC 9099D.
An exit interview was conducted with Executive Director/Administrator (ED/ADM) Maddalena Chavez, a copy of the report and appeals rights were provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026

LIC9099 (FAS) - (06/04)

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Citations on this Visit Report are Under Appeal!

Control Number 26-AS-20260121163506

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: 04/08/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Under Appeal Type A 04/09/2026 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (g)The licensee shall immediately telephone 9-1-1 if an injury ... resulted in an imminent threat to a resident’s health..an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	ED/ADM stated he/she will submit a written plan of correction for staff training on PIN 25-06-ASC, review alternative options based on the PIN. ED/ADM stated written plan of correction will be submitted to LPA by end of POC due date of 04/09/2026.
	8 9 10 11 12 13 14	Based on interview, document reviews, licensee did not ensure that staff are available to meet resident’s needs and staff are adequately trained and equipped to assist residents with lift assistance when it has been determined that the resident has not sustained any injury. Which pose/poses	8 9 10 11 12 13 14	an immediate, health, safety and personal rigths risk to persons in care.
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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: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026

LIC9099 (FAS) - (06/04)

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