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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600133
Report Date: 11/30/2022
Date Signed: 12/01/2022 03:58:11 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
07/01/2021 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210701163514
FACILITY NAME:ATRIA PARK OF SAN MATEOFACILITY NUMBER:
415600133
ADMINISTRATOR:PERRYMAN, DAVIDFACILITY TYPE:
740
ADDRESS:2883 S NORFOLK STTELEPHONE:
(650) 378-3000
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:175CENSUS: DATE:
11/30/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jennifer DuenasTIME COMPLETED:
06:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Staff did not groom resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Jeung met with executive director and reiterated request for May and June 2021 Monthly Assignment Reports for former resident, client #1. These reports document tasks completed by staff in various areas, such as grooming, dressing, status checks, and toiletting. This information was not available previously, and still is not available today.

On 7/9/21, the Department conducted an initial complaint investigation visit regarding the above allegation. Subsequent facility visits were done on 12/29/21, 10/3/22 and 10/24/22.
Based on facility's Resident Functional Needs Assessment dated 5/4/21, client #1 required assistance with preparation and performance of grooming tasks, dressing and undressing 2x/day, status checks 6x/day, and continence support 6x/day. Staff provide care based on the Assessment. The Monthly Assignment Reports documenting completion of these tasks for client #1 are not available for review.

This allegation is determined to be unsubstantiated based on information obtained from staff and facility records. Although this allegation may have occurred or is valid, there is not enough evidence to prove that the alleged violation did or did not occur.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (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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