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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 05:45:58 PM

Unsubstantiated


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
12/15/2022 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20221215083112
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 ThitpTIME COMPLETED:
06:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Insufficient staffing to meet residents' needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Based on review of staff work schedules, observation of facility surveillance video, and interviews with client and staff, this allegation is determined to be unsubstantiated.
On the night of 12/7/22, it was alleged that there was only one staff working in the entire community. Upon review of facility staffing calendars for assisted living and memory care (Life Guidance unit), as well as time cards for 3 staff, there were 4 staff assigned to assisted living and 2 staff assigned to memory care for the overnight shift. On 12/20/22, LPA was advised that there were 87 residents in facility. At 10:52 pm, as per facility surveillance video of front entrance, a female staff is seen responding to emergency personnel and allowing them to enter facility. This is also documented by facility's electronic monitoring of exit doors and resident calls from their rooms or pendants. EMTs were responding to 9-1-1 call from resident in room 223. On the evening of 12/7/22, client in room 223 activated the call alert 5 times before EMTs arrived. Staff responded within 2 minutes, 16 minutes, 28 minutes, 1 minute, and 9 minutes, according to call alert history report. When interviewed on 12/20/22, resident could not recall calling for staff or 9-1-1-on 12/7/22.
Although the allegation may have occurred or is valid, there is not enough evidence to prove the alleged violation did or did not occur.
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)
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