415600133-10-24-2022-14-AS-CSMH-CML2VW-20221229164435

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600133
Report Date: 10/24/2022
Date Signed: 10/24/2022 03:11:25 PM

Substantiated

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
07/01/2021 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210701163514

FACILITY NAME:	ATRIA PARK OF SAN MATEO		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:	10/24/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Jennifer Duenas		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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- Staff did not bathe resident

INVESTIGATION FINDINGS:

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Based on information reported by and obtained from facility records, this allegation is substantiated. The preponderance of evidence standard has been met.

According to care plan for client #1, staff were to assist her with showers 2 days per week. This is documented on facility's Resident Monthly Assignment Report. For the 8 weeks of residency, client #1 should have received 16 showers; however, staff assisted her only 11 times. This information was confirmed by resident services director after reviewing the Assignment Report for May and June 2021. Staff failed to provide client with adequate bathing/showering assistance.

Deficiency of the California Code of Regulations, Title 22 is cited on a following page.

Substantiated

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: 10/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

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-20210701163514

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/07/2022 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	BASIC SERVICES Basic services shall at a minimum include: Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing. This requirement was not met, as evidenced by facility Resident Monthly Assignment Report--in which staff confirm	1 2 3 4 5 6 7	Plan of correction to ensure that clients receive care as specified in care plans will be submitted to CCLD BY DUE DATE
	8 9 10 11 12 13 14	completion of tasks associated with care provided to clients--and care plan--which specifies the care that will be provided by staff. Licensee failed to ensure that client #1 received assistance from staff to shower 2x per week, as agreed to in care plan. This posed a potential health, safety or personal rights risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
07/01/2021 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210701163514

FACILITY NAME:	ATRIA PARK OF SAN MATEO		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:	10/24/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Jennifer Duenas		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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- Resident sustained injury while in care
- Resident's bathroom not maintained clean and sanitary
- Staff did not provide resident with basic laundry service
- Staff did not provide resident with clean bed linen
- Staff did not safeguard resident's personal belongings

INVESTIGATION FINDINGS:

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Based on information from staff and facility records, these allegations are determined to be unsubstantiated.

Complaint alleges that client sustained bruises on arms, and photos taken on 6/3/21 were provided. Some discoloration can be seen in the photos of what appears to be an arm. Staff did not document that bruises were observed prior to this date. Subsequently, however, it is noted that client sustained minor bumps and scratches because she was unsteady.

According to maintenance director, all memory care rooms are thoroughly cleaned once a week. Daily Apartment Cleaning Schedule checklist completed by housekeeping staff document that room--including bathroom--of client #1 was cleaned on 5/3/21 and 6/7/21. Daily Cleaning Schedule Checklists for the other 6 weeks of client's residency are not available. Photos of floor of shower stall and light colored bath mat were provided to show dirt, hair and feces stains on 6/3/21. However, dirt and hair are not visible in the photo of the shower stall floor and the photos do not provide context. It cannot be proven that staff failed to keep client's bathroom clean. Continued on LIC9099C

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: 10/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 14-AS-20210701163514

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: 10/24/2022

NARRATIVE

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Continuation of UNSUBSTANTIATED findings:

According to care plan for client #1, laundry services were scheduled once weekly and done by NoC staff. In addition, caregivers sometimes wash linens if they are observed to be soiled. There is no documentation when soiled linens are observed and washed. Information obtained from caregivers about procedural steps for washing of clients' laundry was confusing and contradictory, and it could not be determined from staff if clients' clothing and/or linens must be labeled with clients' name or room number. Complaint alleges that several items of clothing were missing or damaged. However, items valued at $25 or less are not required to be recorded for safeguarding by facility. LPA was advised by former administrator that client's family was compensated for the items alleged to be missing. Receipts for gift cards were provided to CCLD.

Former client #1 resided in facility May and June 2021. There were difficulties in adjusting to this new environment, as documented in facility notes; she wasn't sleeping at night, demonstrated aggression towards others, and sustained minor bumps and scratches. Medications were reviewed and adjusted.

Although these allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations did or did not occur.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

LIC9099 (FAS) - (06/04)

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