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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600133
Report Date: 10/20/2020
Date Signed: 10/21/2020 10:10:35 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ATRIA HILLSDALEFACILITY NUMBER:
415600133
ADMINISTRATOR:PERRYMAN, DAVIDFACILITY TYPE:
740
ADDRESS:2883 S NORFOLK STTELEPHONE:
(650) 378-3000
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:175CENSUS: 73DATE:
10/20/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Byron Perryman, Administrator TIME COMPLETED:
05:00 PM
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On 10/20/20 LPA Raygoza conducted a Virtual Facetime Case Management visit with Administrator, Byron Perryman. LPA stated purpose of visit and case management commenced. On 10/14/20 an Incident Report was submitted to CCL Office. On 10/12/20 incident occurrence of R1 eloping from window in Memory Care and at that point intercepted. Memory Care window alarm pager alerted staff and R1 was intercepted by staff before exiting building.

LPA toured the Memory Care area and viewed the window alarm that alerted staff. There was no injury and Staff was able to intercept R1 and redirect to Memory Care. After occurrence, R1 was immediately assigned a staff attachment. On 10/13/20, R1 was placed on 1:1 care. Physician specializing in Dementia visited R1 on 10/13/20 and made an in person assessment.

On day of occurrence four (4) caregivers and one (1) Med Tech were assigned to Memory Care for 24 residents. Physician Report, Doctor's Orders, Doctor's Note and Medication list all submitted to CCL Office for R1. Refresher training on elopement was conducted on 10/13/20 for all staff members. Plan in Place and on going 1:1 care for R1 is in place.
This report was discussed and reviewed with Administrator, Byron Perryman.

No Deficiencies Cited today.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha RaygozaTELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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