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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600133
Report Date: 08/31/2022
Date Signed: 08/31/2022 10:24:24 AM


Document Has Been Signed on 08/31/2022 10:24 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:ATRIA PARK OF SAN MATEOFACILITY NUMBER:
415600133
ADMINISTRATOR:JENNIFER DUENASFACILITY TYPE:
740
ADDRESS:2883 S NORFOLK STTELEPHONE:
(650) 378-3000
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:175CENSUS: 101DATE:
08/31/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Executive Director, Jennifer DuenasTIME COMPLETED:
10:30 AM
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On August 31, 2022, Licensing Program Analyst (LPA) Komal Charitra and Investigator, Victoria McIntosh conducted an unannounced Health and Welfare Check inspection. LPA and Investigator met with Regional Vice President, Kris Waluszko and Executive Director, Jennifer Duenas joined shortly thereafter. LPA Charitra explained the purpose of the visit.

During the visit, LPA toured the facility and grounds with Executive Director and Regional Vice President. This is a 3 story facility with Assisted Living (AL) and Life Guidance (LG) being on the 1st floor, and Assisted Living on the 2nd and 3rd floor. There are currently 72 residents in Assisted Living and 27 in Life Guidance.

LPA observed 2 kitchens on the 1st floor, one in the LG department and one in the AL department. According to the Executive Director, the rooms stay locked at all times.

No citations were issued during this visit.

LPA reviewed the report with Executive Director and Regional Vice President and a copy is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
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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