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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600133
Report Date: 10/18/2024
Date Signed: 10/18/2024 10:11:33 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
10/26/2023 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20231026130636
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: 78DATE:
10/18/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kirk BrooksTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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- Staff don't answer facility phone.
INVESTIGATION FINDINGS:
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Based on information reported by and obtained from witness, this allegation is substantiated. The preponderance of evidence standard has been met.

On 10/12/23--not 10/22/23--it is alleged that no one answered the facility phone starting at 11:30 pm for the next 2-3 hours. After 8 pm, a cordless phone is in possession of the nurse on duty until 8 am. Evidence of unanswered calls to facility was provided and this was reported to resident services director the following day.
According to staff schedule, on 10/12/23, LVN and med tech were on duty for AM and PM shifts, as well as 3 or 4 caregivers. An LVN and 2 caregivers were scheduled on the NOC shift.
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After this was brought to the attention of facility management on 10/25/23, regional vice president stated that overnight staff were questioned. It is unknown if the overnight nurse was interviewed.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 14-AS-20231026130636
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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: 10/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
10/25/2024
Section Cited
CCR
87468.1(a)(9)
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PERSONAL RIGHTS
Residents in all residential care facilities for the elderly shall have all of the personal right to have communications to the licensee from their representatives answered promptly and appropriately.
This requirement was not met, as the client's
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Plan of correction to be submitted to CCLD BY DUE DATE
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relative was not able to reach facility by phone on 10/12/23, which posed a potential health, safety or personal rights risk to clients in care. Licensee failed to ensure that telephone communications were responded to promptly.
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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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2