415600133-12-1-2022-14-AS-CSMH-CM9NSM-20221219094322

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600133
Report Date: 11/30/2022
Date Signed: 12/01/2022 04:10:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
07/27/2022 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220727082122

FACILITY NAME:	ATRIA PARK OF SAN MATEO		FACILITY NUMBER:	415600133
ADMINISTRATOR:	JENNIFER DUENAS		FACILITY TYPE:	740
ADDRESS:	2883 S NORFOLK ST		TELEPHONE:	(650) 378-3000
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	175	CENSUS: 82	DATE:	11/30/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Jennifer Duenas		TIME COMPLETED:	06:30 PM

ALLEGATION(S):

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- Questionable death

INVESTIGATION FINDINGS:

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LPA Audrey Jeung conducted an unannounced complaint investigation visit to deliver the findings on the above allegation and met with administrator.
On 07/29/2022, the Department conducted an initial complaint investigation visit regarding the above allegation and obtained copies of documents related to the complaint investigation.

The investigation included interviews with facility staff and medical care providers and review of facility and medical records pertaining to client (C1) who resided in facility until 6/19/22 when C1 was hospitalized.
A review of client’s Needs Services Plan dated 6/1/2022 indicated that client was assessed to need status checks 3x/day, which were documented by staff at midnight, 2am and 4am only. Documentation review showed that staff also logged assistance with monitoring of food choices 3x/day, toileting 2x/day, daily housekeeping and daily reminders for grooming. Client was hospitalized and no longer in the facility as of 6/20/22, yet facility staff documented that assistance, housekeeping and reminders were performed 6/20/22 to 6/26/22. In addition, documentation was maintained for hourly visual checks starting 6/7/22 and ending on 6/18/22 at 1 pm , which were not part of the Needs Services Plan of 6/1/22. There was no documentation that staff observed any injuries or that C1 fell.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022

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 14-AS-20220727082122

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 MATEO	FACILITY NUMBER: 415600133
	VISIT DATE: 11/30/2022

NARRATIVE

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On 6/19/22, visiting family member observed a bruise on client's face. According to staff who checked on client 3 hours earlier, no skin discoloration was observed. Client was transported to hospital and did not return to facility. Upon discharge, he was relocated to another RCFE, and expired on 7/9/22.

Both the Death Certificate and the Coroner's Report identify the immediate cause of death, traumatic subarachnoid hemorrhage and underlying cause, mechanical fall. According to the Coroner's Report, the manner of death was accidental.

Based on investigation conducted by this Department, it is determined that this allegation is unsubstantiated. Although the allegation may have occurred or is valid, there is not enough evidence to prove the alleged violation did or did not occur.

************This report delivered and signed on 12/1/22**************

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022

LIC9099 (FAS) - (06/04)

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