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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600133
Report Date: 11/30/2022
Date Signed: 12/01/2022 04:27:24 PM


Document Has Been Signed on 12/01/2022 04:27 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 MATEOFACILITY NUMBER:
415600133
ADMINISTRATOR:JENNIFER DUENASFACILITY TYPE:
740
ADDRESS:2883 S NORFOLK STTELEPHONE:
(650) 378-3000
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:175CENSUS: 82DATE:
11/30/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jennifer DuenasTIME COMPLETED:
06:30 PM
NARRATIVE
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In response to Incident Reports dated 11/15/22, 11/18/22 and 11/22/22, LPA Jeung met with administrator and reviewed staff and client files:

- Incident of 11/15/22 for client #1 and staff #1
- Incident of 11/18/22 for client #2
- Incident of 11/22/22 for client #3
- Incident of 10/27/22 for client #4

During today's visit, LPA participated with law enforcement interview of client #3 regarding incident reported on 11/22/22.

Based on Incident Report of 10/27/22, a deficiency of the California Code of Regulations, Title 22 is cited on a following page.

************This report is delivered and signed on 12/1/22**************
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
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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Document is an Amendment of Original Document on 03/01/2023 04:52 PM

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: 11/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
12/02/2022
Section Cited

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CRIMINAL RECORD CLEARANCE
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility obtain a CA clearance or a criminal record exemption as required by the Dept.
This requirement was not met, as Staff #2
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Plan of correction to be submitted to CCLD BY DUE DATE, in which administrator acknowledges criminal record clearance and association requirements, as discussed
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worked as a caregiver for 5 days, but did not have criminal record clearance and association with facility. Licensee failed to ensure that this agency staff had criminal record clearance and association with facility, which posed an immediate health, safety or personal rights risk to clients. DOJ Clearance letter dated 12/21/21 is provided to LPA on 12/1/22
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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: Vivien HelblingTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cara SmithTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
LIC809 (FAS) - (06/04)
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