Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600133
Report Date: 08/19/2021
Date Signed: 08/19/2021 02:31:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ATRIA PARK OF SAN MATEOFACILITY NUMBER:
415600133
ADMINISTRATOR:CECILIA DAUTHFACILITY TYPE:
740
ADDRESS:2883 S NORFOLK STTELEPHONE:
(650) 378-3000
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:175CENSUS: 90DATE:
08/19/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Shanel Thitphaneth and Reiko KitamoriTIME COMPLETED:
01:30 PM
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In response to Incident Report dated 8/14/21, LPA Jeung met with resident services director and memory care director to obtain additional details about elopement of resident. LPA reviewed resident's file and observed room that resident exited facility from, as well as the room that he occupies, and reviewed procedures and processes--identifying who was working and who was responsible for responding to the alarm. Based on this incident, facility will implement new processes to prevent recurrence and submit addendum to Incident Report within 5 business days.

There are 32 residents in memory care unit and 5 caregivers present today.

See separate Facility Evaluation Report for additional observations.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
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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