415600133-1-26-2023-14-AS-CSMH-CNGPJS-20230127102200

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600133
Report Date: 01/26/2023
Date Signed: 01/26/2023 03:34:46 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
09/07/2022 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220907162023

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: 87	DATE:	01/26/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Executive Director, Jennifer Duenas		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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-Staff failed to observe change in resident's condition
-Staff failed to report change of condition as required
-Staff failed to obtain medical intervention
-Staff spoke disrespectfully to client
-Staff is roughly handling client

INVESTIGATION FINDINGS:

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On January 26, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Executive Director, Jennifer Duenas and explained the purpose of the visit.

Regarding the allegation, staff failed to observe change in resident's condition and staff failed to report change of condition, according to the reporting party, on 8/14/22, the facility reported that Resident #1's (R1's) left hand was red and swollen. In addition the reporting party indicated that R1 had bumps on his/her shoulders, head, legs and foot, however staff failed to observe and report R1's change of condition after the issue was addressed with the Life Guidance Director.

During the investigation, LPA interviewed staff and reviewed R1's file. Based on file reviewed, the facility contacted R1's physician on 8/10/22 and notified the physician when there was a change of R1's condition. In addition, LPA reviewed facility resident's notes for R1 and observed R1's change of condition documented as required. Furthermore, according to the staff interviewed, when R1's condition was addressed, the facility staff ensured to document and notify the Life Guidance Director or the Administrator if there was a change of condition.

CONT. TO 812C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

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-20220907162023

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: 01/26/2023

NARRATIVE

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Regarding the allegation that staff failed to obtain medical intervention, according to the reporting party, R1 was observed to have bumps on his/her body and the staff assisting R1 to dress/undress did not seek appropriate medical intervention. During the investigation, LPA reviewed R1's file and interviewed staff. Based on file reviewed, the facility staff documented any change of condition as needed and was in communication with R1's physician regarding any change of condition R1 had. In addition, interviewed staff acknowledged that R1 has a history of skin condition and if R1 did have a change of condition, they notified the Administrator or the Life Guidance Director.

Regarding the allegation that staff spoke disrespectfully to clients and that staff is roughly handling clients, according to the reporting party, a staff member (name and description not identified) at the facility was rough with dressing R1 and when R1 told staff to slow down due to pain, the staff member told R1 to not tell him/her what to do in a rude tone. During the investigation, LPA interviewed the staff members, residents, and residents’ responsible parties. According to the residents interviewed, it was indicated that they really enjoy being around the staff and the staff are helpful when they need them. In addition, according to the responsible parties interviewed, it was indicated that they have good communication with the staff and they appreciate them. Furthermore, responsible parties interviewed, indicated that they never had any issues with the staff members.

Therefore, based on the documents reviewed and interviews conducted, the allegations above are UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

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