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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600133
Report Date: 12/04/2023
Date Signed: 12/04/2023 04:44:59 PM


Document Has Been Signed on 12/04/2023 04:44 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:
12/04/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Kirk BrooksTIME COMPLETED:
04:45 PM
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In response to and as per Stipulation/Waiver/Order dated 11/29/23, LPA Jeung observed the following:

1. Secure storage of cleaning compounds, detergents and poisons in main kitchen and locked rolling carts in storage room
2. Proper labeling of cleaning compounds, detergents and poisons in kitchen
3. Appropriate signage in main and LG kitchen and dining rooms that food and beverage containers can only be used for food and beverages
4. Staffing in memory care unit (Life Guidance) of 4 caregivers for 21 LG residents

Mr. Brooks acknowledges conditions of Stipulation, including additional staff training and reporting requirements.

No deficiency cited.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2023
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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