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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600133
Report Date: 08/31/2023
Date Signed: 08/31/2023 06:11:31 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
09/12/2022 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220912164209
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: 81DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Jennifer Duenas and Shanel Thitphaneth TIME COMPLETED:
06:30 PM
ALLEGATION(S):
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 - Staff failed to provide basic care services
INVESTIGATION FINDINGS:
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Based on review of facility and hospice records and interviews with staff, this allegation is substantiated. The preponderance of evidence standard has been met.

Client #1 was a hospice resident for 35 days in July and August 2022. Based on Physician's Report of 6/23/22 and facility Functional Needs Assessment of 7/2/22--signed by client's responsible party--a Functional Needs Service Plan was developed and signed by client's responsible party on 7/2/22. Although basic care services such as assistance with dressing, undressing, and toileting are identified in assessment and service plan, the level of assistance needed appears to have been underestimated.
Staff provided stand-by/reminder assistance with maintaining the commode 3 times daily, but client needed moderate to extensive assistance with toileting--assistance to/from bathroom and cleansing after voiding. Per the assessment and service plan, staff provided supervision to select clothing and occasional help with dressing and undressing twice daily, but on more than one occasion, client was observed in pajamas in the afternoon. Continued
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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 5
Control Number 14-AS-20220912164209
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
VISIT DATE: 08/31/2023
NARRATIVE
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Staff confirm completion of tasks on a Monthly Assignment Report, which reflects the assessment and service plan developed by facility staff and agreed upon by client's responsible party. Based on a review of the Assignment Report for July and August 2022, client was assisted by staff with dressing and undressing twice a day and stand-by/reminder assistance to maintain the commode 3 times daily, except for 2 mornings and 3 afternoons/evenings.

Despite the inaccuracy of the Assessment and Service Plan, facility was responsible for providing assistance with activities of daily living. Deficiency of the California Code of REgulations, Title 22, is cited on a following page.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 14-AS-20220912164209
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: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2023
Section Cited
CCR
87464(d)
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BASIC SERVICES
... the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal... and providing the other basic services specified below, either directly or through outside resources.
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Plan of correction to be submitted to CCLD BY DUE DATE
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This requirement was not met, as staff failed to provide consistent dressing, undressing and toileting assistance to client #1. Licensee failed to ensure that client received the appropriate level of care needed, which posed a potential health, safety, or 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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
09/12/2022 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220912164209

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: 81DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Jennifer Duenas and Shanel TIME COMPLETED:
06:30 PM
ALLEGATION(S):
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- Staff failed to observe and/or report coccyx sore
- Staff failed to seek medical intervention for coccyx sore
- Staff did not respond in timely manner to emergency call
- Staff failed to provide all of client's medications to family when client moved to family home, causing client to miss doses
INVESTIGATION FINDINGS:
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Based on review of facility and hospice records and interviews with staff, these allegations are determined to be unsubstantiated.

As per client's Functional Needs Assessment of 7/2/22--signed by client's responsible party--and Functional Needs Service Plan--staff provided extensive showering/bathing assistance once weekly. In addition, hospice aides were to provide perineal care when they visited 4 days a week, and assist with bathing/showering 3 times per week. On 7/18/22, hospice RN noted "mild redness" on buttocks, but "no skin breakdown." Two days later, another visiting nurse noted that client's skin was "clear." Facility staff did not document observation of any redness or sores, so staff did not seek medical intervention. As per hospice agreement between hospice provider and facility, hospice staff are responsible for reporting condition updates to responsible parties.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20220912164209
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
VISIT DATE: 08/31/2023
NARRATIVE
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According to facility's SmartCare emergency call system records, client called for staff assistance only two times; both times staff responded within one minute. There are no records of additional calls from client's room during the time she resided in facility.

Due to COVID cases in facility, client #1 was moved temporarily from facility after 35 days by her family, and medications for the anticipated 5 days of absence were provided. After 5 days, it was decided that client would not return to facility, and additional medications were provided to the family. According to facility staff, all of client's remaining medications were given to the family. Based on medication records, those medications were filled on 7/12/22 for a 30-day supply, so very few medications were received by client's family on 8/11/22.

According to facility's report of medications refilled for client #1, staff reordered client's medications on 8/6/22 and 8/11/22. Subsequently, the 7 medications reordered on 8/11/12 were not refilled, because client relocated on 8/15/22. All remaining medications were relinquished to family on 8/14/22.

Although the allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations did or did not occur.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5