415600133-3-15-2021-14-AS-KHOS-BZ7KGP-20210317075348

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600133
Report Date: 03/15/2021
Date Signed: 03/15/2021 04:14:45 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/27/2020 and conducted by Evaluator Bertha Raygoza

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200227163252

FACILITY NAME:	ATRIA PARK OF HILLSDALE		FACILITY NUMBER:	415600133
ADMINISTRATOR:	PERRYMAN, DAVID		FACILITY TYPE:	740
ADDRESS:	2883 S NORFOLK ST		TELEPHONE:	(650) 378-3000
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	175	CENSUS: 92	DATE:	03/15/2021
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Cecilia Dauth, Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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- Staff not meeting resident's medical needs
- Staff not transporting resident to appointments

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Raygoza made an unannounced complaint virtual visit on the above allegations and met with Administrator, Cecilia Dauth. LPA Raygoza stated the purpose of virtual visit.

- Staff not meeting resident's medical needs. During the course of investigation, the medical records, Appointment Schedule and Senior Helper Escort log indicating R1 attending the medical appointments on 1/29/20, 2/19/20, 2/24/20, 2/25/20 and 2/27/20 all documented on logs. Interviews of staff drivers and senior helper escorts supporting the documentation that medical appointments were attended and, therefore the allegation was deemed Unsubstantiated.
- Staff not transporting resident to appointments. Doctor Appointment logs and Transportation log indicating on 2/25/20 from 1pm to 4:13 pm sign-out and 2/27/20 from
9 am to 12 noon sign-out of staff taking R1 to Home Care Appointments. Therefore, the allegation was deemed Unsubstantiated.

Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time.

This report was reviewed and discussed with Cecilia Dauth, Administrator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha Raygoza	TELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021

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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