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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600133
Report Date: 08/15/2023
Date Signed: 08/15/2023 05:22:58 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
02/27/2023 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230227124505
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: 80DATE:
08/15/2023
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Jennifer Duenas and Shanel ThitphanethTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff did not notify resident's responsible party of a change in condition
INVESTIGATION FINDINGS:
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Based on investigation conducted by this Department, which included review of facility records, medical and hospice records, and interviews with hospice and facility staff and witnesses, this allegation is determined to be substantiated. The preponderance of evidence standard has been met.

Client #1 was admitted to hospice in December 2021 and was noted by visiting nurse to have a pressure injury on the heel in November 2022. Home health nurses were ordered by MD in December 2022 to treat the stage II heel ulcer one or two times per week. On 1/3/23, a visiting nurse described the wound as unstageable on a facility form documenting for the facility the client's condition and treatment; hospice MD was notified, but client's family was not notified. Despite initialling acknowledgement of the nurse's visit, resident services director became aware of the unstageable heel injury when a visiting family member observed the heel injury on 1/7/23 and reported it to facility staff. A hospice nurse was requested to visit on the same day, and subsequent nursing visits followed on 1/8/23 and 1/9/23.

According to agreement between hospice provider and facility, hospice staff is responsible for reporting condition updates to responsible parties.
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: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
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 4
Control Number 14-AS-20230227124505
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: 08/15/2023
NARRATIVE
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Although the hospice agency was responsible for providing updates to client's family, staff failed to monitor client's condition based on visiting nursing assessments. 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: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 14-AS-20230227124505
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: 08/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
08/25/2023
Section Cited
CCR
87466
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OBSERVATION OF THE RESIDENT
The licensee shall ensure that residents are regularly observed for changes in physical...functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as...deterioration of...a physical health condition are observed,
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Plan of correction to be submitted to CCLD BY DUE DATE
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the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met, as licensee failed to notify POA when hospice LVN observed unstageable wound, which poses an immediate health & safety risk.
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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: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
02/27/2023 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230227124505

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: 80DATE:
08/15/2023
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Jennifer Duenas and Shanel TTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Licensee neglect resulted in resident sustaining unstageable pressure injury
INVESTIGATION FINDINGS:
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Based on investigation conducted by this Department, which included review of facility records, medical and hospice records, and interviews with hospice and facility staff and witnesses, this allegation is determined to be unsubstantiated.

As per Atria policy, "all wound care must be provided by an outside provider according to physician's orders." That facility staff are not to examine wounds or remove dressing applied by visiting nurses was corroborated by staff interviews.

Although staff did not observe wound condition nor provide wound care, they failed to monitor nursing assessments of the wound in a timely manner. This may have caused a delay in wound treatment by hospice care team. This allegation may have occurred or is valid, but 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: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
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 4