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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600133
Report Date: 10/31/2023
Date Signed: 10/31/2023 12:05:37 PM

Document Has Been Signed on 10/31/2023 12:05 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: DATE:
10/31/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Kris WaluszkoTIME COMPLETED:
12:15 PM
NARRATIVE
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During complaint investigation regarding client #1, who was admitted on 8/19/23, a deficiency of the California Code of Regulations, Title 22 was observed. The complaint investigation was concluded and Complaint Investigation Report was delivered to facility on 10/10/23.

Upon client's admission on 8/19/23, her medications were brought to facility. Resident services director ensured that medications list and other required documents were obtained to initiate administration of medications in coordination with facility's pharmacy. As per facility protocols for new residents, staff were to confirm that pharmacy received required medication information and send medication administration record to facility, in addition to logging medications on Centrally Stored Medications Record.

As a result of staff's failure to follow up regarding medications as instructed, and failure to recognize the needs of the new resident, she did not receive any medications for 24 hours, including insulin. It was only when responsible party visited on 8/20/23 and observed client looking unwell and vomitting that 9-1-1 was called. Facility LVN did not adequately respond to client's condition until family insisted that 9-1-1 be called. Client's blood sugar was very high, and she required subsequent intensive care hospitalization.

Deficiency is cited and $500 civil penalty assessed on following pages.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/31/2023 12:05 PM - It Cannot Be Edited


Created By: Audrey Jeung On 10/25/2023 at 11:53 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2023
Section Cited

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INCIDENTAL MEDICAL CARE
The licensee shall assist residents with self-administered medications as needed.
This requirement was not met, as staff did not provide medications to client #1 on 8/19/23 and 8/20/23, which resulted in medical emergency and intensive care
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hospitalization. Licensee failed to ensure that resident was provided with required medications, which posed an immediate health, safety or personal rights risk to clients in care. $500 civil penalty is assessed, as this violation caused client to require intensive medical care. See LIC421IM.
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Type A
11/01/2023
Section Cited

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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 ... physical health conditions are observed, the
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licensee shall ensure that such changes are documented and brought to the attention of the resident's physician... This requirement was not met, as facility LVN did not respond appropriately when client was vomitting, which posed an immediate health, safety or personal rights risk to clients in care.
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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 Smith
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023


LIC809 (FAS) - (06/04)
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