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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600133
Report Date: 03/28/2025
Date Signed: 03/28/2025 02:00:13 PM

Unfounded


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
02/12/2025 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250212161149
FACILITY NAME:ATRIA PARK OF SAN MATEOFACILITY NUMBER:
415600133
ADMINISTRATOR:BROOKS, THOMAS KIRKFACILITY TYPE:
740
ADDRESS:2883 S NORFOLK STTELEPHONE:
(650) 378-3000
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:175CENSUS: 78DATE:
03/28/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Resident Services Director - Paula SpanekTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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- Unlawful eviction
- Facility did not conduct reassessment of resident
- Facility failed to provide services in admission agreement
- Medication error
INVESTIGATION FINDINGS:
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On 03/28/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to begin the investigation process regarding the allegations received. LPA met with resident services director Paula Spanek and explained the purpose of today's visit. During the course of the investigation LPA conducted interviews, made observations, and reviewed pertinent documents received related to the allegations received.

In regards to unlawful eviction, per documentation recieved the eviction notice is valid. The eviction complied with licensing requirements and did state it was for a 30 day eviction, not 10 as originally reported. This was issued based on resident assessments conducted and the needs of the resident requiring a higher level of care.

In regards to the facility not conducting reassessments, based on facility records reviewed, the resident was assessed numerous times up until the last assessment which resulted in the eviction noticed being issued due to the need of a higher level of care. Change of condition notices are also documented reflecting assessments.

Continued on next page...
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
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-20250212161149
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
VISIT DATE: 03/28/2025
NARRATIVE
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In regards to failing to provide services in admission agreement, LPA reviewed the admission agreement of the facility and found that it contained the necessary information. It also states the conditions that may lead to reassessment and termination of residency. Additionally, the facility does not provide one on one care, the facility cannot provide services to a resident if they are bedridden, and if the facility cannot meet the needs of a resident the facility may terminate residency. Based on the items reviewed in this section of the admission agreement, and review of the assessments conducted, the facility had a basis for eviction.

In regards to medication error, the resident received medication as prescribed. Documentation reviewed indicates the medications of the resident was provided as prescribed. Medications were reviewed as current. The facility provided documentation of the resident's medication administration records and medications are shown as provided accurately based on prescription. Based on interviews and documentation reviewed the facility provided medications as prescribed.

This agency has investigated the complaint alleging, Unlawful eviction: Facility did not conduct reassessment of resident; Facility failed to provide services in admission agreement; Medication error . We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

This report is reviewed with resident services director Paula Spanek and a copy of this report is provided on this day.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2