<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600133
Report Date: 02/03/2023
Date Signed: 02/03/2023 05:37:46 PM


Document Has Been Signed on 02/03/2023 05:37 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: DATE:
02/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Resident Service Director, Shanel ThitphanethTIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 2/3/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management visit to deliver an amended report that was provided on February 2, 2023 by LPA Murial Han and LPA Komal Charita in reference of complaint number 14-AS-20220829165142. LPA Han met with Resident Service Director, Shanel Thitphaneth and explained the purpose of the visit. This report is amended to correct immediate exclusion orders were issued for S1, S2, S3 and S5.

During the visit, LPA reviewed the amended report and provided a copy of it to resident service director, Shanel Thitphaneth .

This report is reviewed and discussed with resident service director over the phone and a copy is provided via electronically.

Resident service director will sign this report and return it to LPA by 5:30pm on 2/3/2023.

Signed LIC809- case management visit.pdfSigned LIC809- case management visit.pdf





SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1