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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600133
Report Date: 12/20/2024
Date Signed: 12/20/2024 01:29:51 PM

Document Has Been Signed on 12/20/2024 01:29 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ATRIA PARK OF SAN MATEOFACILITY NUMBER:
415600133
ADMINISTRATOR/
DIRECTOR:		BROOKS, THOMAS KIRKFACILITY TYPE:
740
ADDRESS:2883 S NORFOLK STTELEPHONE:
(650) 378-3000
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 175CENSUS: 72DATE:
12/20/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Activities Director - Angie SerraonTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 12/20/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - legal/non-compliance visit in response to and as per Stipulation/Waiver/Order dated 11/29/23. LPA met with activities director Angie Serraon.

LPA Vado observed the following per the Stipulation/Waiver/Order:

1. Secure storage of cleaning compounds, detergents and poisons in the LG (Life Guidance) prep kitchen. Main kitchen and locked rolling carts in storage room are observed as secured.
2. Proper labeling of cleaning compounds, detergents and poisons in kitchen and LG prep kitchen.
3. Appropriate signs in main and LG kitchen and dining rooms that food and beverage containers can only be used for food and beverages. This is observed in both LG and the main dining room
4. Staffing in memory care unit (LG) of 5 caregivers for 26 LG residents and 1 housekeeper in this area. Lavander Halafu the life guidance director is present in the LG kitchen and provided LPA with the staffing ratios.
6. LPA observed the posting of the Stipulation/Waiver/Order dated 11/29/23 in a framed box near courtyard door near the activity room

The administrator Kirk Brook is not present on this day but Angie acknowledges conditions of Stipulation, including additional staff training and reporting requirements.

No deficiency cited.
April Cowan
Jaime Vado
DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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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