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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600133
Report Date: 03/23/2021
Date Signed: 03/23/2021 03:18:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
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:
03/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Cecilia Dauth, AdministratorTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Raygoza made an unannounced case management virtual visit and stated purpose of visit to Administrator, Cecilia Dauth.

During the investigation of complaint 14-AS-20200520143002, information provided indicated that R1 had a change of condition, developing a stage 3 pressure wound that is a prohibited health condition. The licensee failed to request an exception to retain the resident and failed to provide higher level of care. The home health nurse communicated the worsening of the resident's condition, but the licensee failed to act appropriately. It was also indicated that no provisions were made to have the resident transfer to a higher level of care facility. Therefore, there is preponderance of evidence to show that the licensee failed to ensure proper care of the resident's needs by failing to follow PCHH instructions on wound care. During the period of 04/18/20 through 4/24/20, the Administrator did not fulfill Administrator's Qualifications and Duties. Therefore, the facility is cited under Section 87405(d)(1)(2) Administrator Qualifications and Duties.

This report was discussed and reviewed with Administrator, Cecilia Dauth.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha RaygozaTELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 03/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2021
Section Cited

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87405(d)(1)(2) Administrator - Qualifications and Duties - (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
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This requirement is not met as evidenced by; The licensee failed to request an exception to retain the resident and failed to provide higher level of care. The home health nurse communicated the worsening of the resident's condition, but the licensee failed to act appropriately. Licensee failed to ensure proper care of R1's needs by failing to follow PCHH instructions on wound care.
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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: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha RaygozaTELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2021
LIC809 (FAS) - (06/04)
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