415600133-9-20-2023-14-AS-KHOS-CW8K77-20231002073841

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600133
Report Date: 09/20/2023
Date Signed: 09/20/2023 05:09:51 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
12/16/2022 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20221216152340

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: 83	DATE:	09/20/2023
		UNANNOUNCED	TIME BEGAN:	04:45 PM
MET WITH:	Shanel Thitphaneth and Alisa Salluce		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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- Staff did not properly supervise resident

INVESTIGATION FINDINGS:

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Based on review of facility records--including client records--and interviews with staff, this allegation is determined to be unsubstantiated.

As per Incident Report submitted to CCLD on 12/12/22, client #2 was observed exiting room of client #1 at approximately 3 am. Both are residents of memory care unit, where 2 caregivers are scheduled on the overnight shift for up to 40 residents. Both clients denied that anything happened. Client #1 did not exhibit any distress and was assessed for injuries. Based on Needs Assessment and Service Plan for client #2, he is prone to wandering, so staff provide hourly status checks, which were documented at 2am, 3am and 4am.
Despite this incident, staffing appears to have been appropriate to care and supervise 21 memory care residents on 12/12/22.

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 Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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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