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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600133
Report Date: 03/21/2023
Date Signed: 03/21/2023 10:54:32 AM


Document Has Been Signed on 03/21/2023 10:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 MATEOFACILITY NUMBER:
415600133
ADMINISTRATOR:JENNIFER DUENASFACILITY TYPE:
740
ADDRESS:2883 S NORFOLK STTELEPHONE:
(650) 378-3000
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:175CENSUS: 79DATE:
03/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shanel ThitphanethTIME COMPLETED:
11:00 AM
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LPA Jeung met with resident services director to confirm that the Department's Accusations for license revocation, administrator de-certification, and 4 staff exclusions have been received and acknowledged.

Administrator Jennifer Duenas was available by phone and advised LPA that written notice of the accusations was given to residents, their responsible parties and local Ombudsman program. LPA observed an undated posting partially entitled Reactive Talking Points that acknowledges the Dept.'s license revocation action. Copy of written notice is obtained, as well as client roster with responsible parties.

LPA reviewed Health and Safety Code 1569.38 with Ms. Thitphaneth.

No deficiency cited during today's visit.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023
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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