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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600133
Report Date: 12/14/2022
Date Signed: 01/24/2023 03:49:28 PM


Document Has Been Signed on 01/24/2023 03:49 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: 87DATE:
12/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:April Bennett and Kris WaluszkoTIME COMPLETED:
02:45 PM
NARRATIVE
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During complaint investigation visit, LPA Jeung observed a deficiency of the California Code of Regulations, Title 22, which is cited on a following page
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
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 2


Document Has Been Signed on 01/24/2023 03:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
12/15/2022
Section Cited

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CRIMINAL RECORD CLEARANCE
A licensee may request a transfer of a criminal record clearance from one state licensed facility to another, by providing the following documents to the Dept:
(1) A signed LIC 9182 with a copy of the individual's CA driver's license, or valid ID card issued by the CA DMV, or valid photo

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Plan of correction to be submitted to CCLD BY DUE DATE
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ID issued by another state or the U.S. government. This requirement was not met, as former director of culinary services, Staff #4, was employed from12/29/21 until 11/21/22, but criminal record clearance was not associated to this facility. Licensee failed to ensure that staff maintained criminal record clearance & assoication to facility, which posed an immediate health, safety, personal rights risk.
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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
LIC809 (FAS) - (06/04)
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