415600133-12-14-2022-14-AS-JVAO-CM4UBZ-20221214142710

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600133
Report Date: 12/14/2022
Date Signed: 12/14/2022 02:27:24 PM

Document Has Been Signed on 12/14/2022 02:27 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	ATRIA PARK OF SAN MATEO		FACILITY NUMBER:	415600133
ADMINISTRATOR:	JENNIFER DUENAS		FACILITY TYPE:	740
ADDRESS:	2883 S NORFOLK ST		TELEPHONE:	(650) 378-3000
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	175	CENSUS: 87	DATE:	12/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Kris Waluszko		TIME COMPLETED:	02:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual required 1 year inspection focused on COVID infection control. LPA met with reginal vice president Kris Waluszko and explained the purpose of today's inspection visit. Upon entry LPA was COVID screened via questions and had temperature taken by the front desk staff person. LPAs identifying information and contact information was provided to the staff person. Upon entry, LPA did observe COVID postings on the front table. LPA toured facility's building and grounds. LPA observed COVID postings through out the facility. LPA advised that on the second and third floor more COVID signs be placed through out the hallways and any common areas. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. Resident and staff daily temperature log is observed as current. PPE supply is observed as in place. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Fire extinguishers are observed through out the facility and are tagged as being inspected on 06/01/22. LPA observed four fire extinguishers and all are charged and dials read as within specifications. In the kitchen LPA observed the Ansul system as being inspected on 11/03/22. Facility ambient temperature is comfortable. Facility lighting is sufficient for residents and staff safety. Continued on attached LIC809-C

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
	VISIT DATE: 12/14/2022

NARRATIVE

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Page 2 - Required 1 Year Annual

Water temperature is tested at 108F in a common bathroom on the ground floor. Another common bathroom water temperature is tested at 110F on the third floor. Of the resident rooms observed, rooms 112 and 221, they are equipped with the required furniture and light fixtures. Non-skid mat is in place in room 112 and grab bars are present in both resident bathrooms. Resident room shower floors are equipped with non-skid flooring. Liquid soap is available and paper towels are available in common bathrooms. First-aid kits are inspected as complete. A Disaster and Mass Casualty Plan is posted. Staff are observed wearing masks. Criminal record clearances or exemptions for facility staff or other individuals who have client contact is reviewed. S1 is discovered to not have a completed fingerprint clearance at this time and has been working in the facility since Administrator certificate is observed as current. Facility does not handle resident monies. LPA also reviewed resident records during today's inspection. All staff and residents have been vaccinated.

The following updated forms are requested to be submitted to CCLD by 12/21/2022:

• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan
• Copy of administrator certificate

Citation is issued on the following LIC809D. A civil penalty is being assessed in the amount of $300 on this day which is outlined on the attached LIC809D and LIC421BG.

Report is reviewed with Kris Waluszko.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/14/2022 02:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type A

Section Cited

CCR

87355(e)(1)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, and schedule review, the licensee did not comply with the section cited above in 1 out of 5 agency persons reviewed, S1 did not have a current criminal record clearance, which poses an immediate health, safety or personal rights risk to persons in care. S1's criminal record clearance is in a pending status as of 12/07/2022. LPA Vado confirmed on this day that the clearance is still in a pending status and is still not considered to be cleared. S1 has been working in the facility as confirmed by the weekly schedule. S1 shows working three days this week as of today's inspection.
	POC Due Date: 12/15/2022
	Plan of Correction
1 2 3 4	Licensee shall ensure to submit evidence of final fingerprint clearance status as well as a written plan of correction on how to prevent this for occurring in the future as well as actions taken regarding S1 until clearance is approved.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022

LIC809 (FAS) - (06/04)

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