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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600133
Report Date: 10/10/2023
Date Signed: 10/10/2023 06:44:30 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
08/22/2023 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230822132352
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: 79DATE:
10/10/2023
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Corrine Tanchoco and Shanel ThitphanethTIME COMPLETED:
06:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not provide adequate food service.
Staff does not ensure resident's showering needs are being met.

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Based on review of staff schedules, client shower schedules, and interviews with clients and staff, these allegations are determined to be unsubstantiated.

According to administrator and posted menus, breakfast is served from 7:30 - 9:30 am, lunch 11:30 am - 1:00 pm, dinner 4:30 - 6:00 pm. Some residents require staff to escort them from their rooms to the dining room. Especially in the morning, this delay may infrequently cause some residents to miss breakfast in the dining room. The Bistro offers light breakfast after the main kitchen closes.

There are 39 assisted living residents who are assisted by staff to bathe or shower once or twice a week; 26 are scheduled for mornings, and 13 for afternoons and evenings. At times, morning staff are unable to provide assistance to all residents scheduled for showers, and pass this task to PM staff. All 5 residents that LPA spoke with had no complaints that staff neglected their showering needs.

Although the allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations 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: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
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 2
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
08/22/2023 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230822132352

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: 79DATE:
10/10/2023
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Corrine Tanchoco and Shanel ThitphanethTIME COMPLETED:
06:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure residents have prescription orders to administer resident's medications.
Staff do not conduct proper assessment of resident(s) prior to admissions.

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
These allegations have been investigated by the Community Care Licensing Division of the CA Department of Social Services, and determined to be unfounded. This means that the allegations could not have happened and/or are without a reasonable basis.

When client #1 was admitted to facility on 8/19/23, Physician's Report for RCFE, Preplacement Appraisal, Functional Needs Assessment, Functional Needs Service Plan and signed MD medication orders were already completed and reviewed. On 8/20/23, due to lack of oversight, staff failed to ensure that client received required medications, including 4x/day insulin injections and heart medications. This incident resulted in a medical emergency, which was reported to licensing agency as required. In addition, based on facility's internal investigation, two staff involved were terminated.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2