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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600133
Report Date: 12/01/2022
Date Signed: 12/01/2022 04:32:35 PM


Document Has Been Signed on 12/01/2022 04:32 PM - 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: 82DATE:
12/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Jennifer DuenasTIME COMPLETED:
04:45 PM
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LPA Jeung followed up on 11/30/22 case management and complaint visits to deliver Facility Evaluation Reports and Complaint Investigation Reports which could not be delivered on that day due to technical difficulties. All reports dated 11/30/22 are reviewed, discussed with and delivered to administrator today.

Today, Order of Immediate Exclusion for staff #1 is given to Ms. Duenas, pertaining to incident of 11/15/22.

No deficiencies cited today for this LIC809.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022
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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