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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600133
Report Date: 09/15/2022
Date Signed: 09/15/2022 04:27:32 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
08/05/2022 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220805164749
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: 94DATE:
09/15/2022
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Chris Waluszko, Reiko Kitamori, Shanel T.TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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- Facility staff did not follow Covid-19 safety protocols
INVESTIGATION FINDINGS:
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Based on investigation conducted by LPA Jeung and observations made on 8/12/22 during initial complaint visit, this allegation is substantiated. The preponderance of evidence standard has been met.

On 8/12/22, manager on duty and resident services director accompanied LPA and observed that N95 respirators, gowns, gloves and donning and doffing instructions are not maintained in isolation carts outside of 8 client apartments where clients with COVID reside. A notice was posted on the isolation rooms: "STOP--Full PPE required beyond this point: gloves, N95 mask, eye protection, gown." LPA observed folding tray tables outside of the isolation rooms--some with a medical gown enclosed in a plastic wrap, but no other PPE--and 2 rooms with covered waste containers in the hall. This was discussed with manager on duty and resident services director during the visit.

Deficiency of the CA Code of Regulations, Title 22 is cited on a following page.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
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-20220805164749
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
09/16/2022
Section Cited
CCR
87468.1(a)(2)
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PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES
Residents in all RCFEs shall have the personal right to be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met, as COVID isolation rooms were not properly equipped
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Per resident services director, isolation carts were installed outside of all COVID isolation rooms on 8/13/22, filled with N95s, gloves, gowns, hand sanitizers, brown paper bags, including donning and doffing instructions.
Plan of correction to be submitted to CCLD BY DUE DATE
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with full PPE--including donning and doffing instructions--maintained outside of rooms for use by caregivers. Licensee failed to ensure that residents were accorded a safe and healthy environment, as full PPE was not properly maintained for use by caregivers. This poses an immediate health, safety and personal rights risk to clients in 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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC9099 (FAS) - (06/04)
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