415600133-10-10-2023-14-AS-KHOS-CY2K76-20231129063834

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600133
Report Date: 10/10/2023
Date Signed: 10/10/2023 06:29:58 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
01/24/2023 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230124115346

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: 79	DATE:	10/10/2023
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Corrine Tanchoco and Shanel Thitphaneth		TIME COMPLETED:	06:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-Staff do not ensure that resident's hygiene needs are met
-Staff do not ensure that resident's diapering needs are met
-Staff do not ensure that residents are provided with a sufficient amount of liquids
-Staff do not respond to resident's requests for assistance
-Staff are not adequately trained
-Personal Rights--Resident sustained unexplained injuries/bruising

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Based on review of facility records and interviews with clients and staff, these allegations are determined to be unsubstantiated.

According to facility's Monthly Assignment Reports for the period January 2022 to January 2023 for client #1, staff provided showering assistance once a week. In addition, staff assisted client with hygiene and toiletting 7 times/day, and dressing, grooming and offering fluids twice a day. Although facility records do not reflect that staff confirmed completion of each task consistently, there is insufficient information to prove that client's hygiene, diapering and hydration needs were unmet.

There is not enough information or evidence that staff ignored client's request for help to wash her hands.

Complaint alleges that due to lack of training, staff did not properly secure soiled diapers and assist client to brush teeth. This staff is no longer employed. Some training records for 20 staff were reviewed.
Continued on next page.

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: 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 3

Control Number 14-AS-20230124115346

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: 10/10/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

In January, February and March 2022, bruises were observed on client #1 arms, legs, back, shoulder, and eye. Facility staff documented the unexplained bruising, and noted that client was taking blood thinning medications, which caused skin to bruise easily. During this time, client was also observed to be flailing her arms and screaming, which may have resulted in unintentional bruising. Based on the Department's investigation, there is no evidence that staff failed to supervise and care for client.

Although the allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations did or did not occur.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
01/24/2023 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230124115346

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: 79	DATE:	10/10/2023
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Corrine Tanchoco and Shanel Thitphaneth		TIME COMPLETED:	06:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-Staff physically abused residents in care
-Facility charged resident for services not provided

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Allegations of physical abuse and unwarranted charges 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.

Because of the lack of additional information and the unavailability of the alleged victim and suspected staff, allegation of physical abuse could not be properly investigated. There is no evidence that residents were physically abused by staff. Alleged abuse of former resident by former staff may have occurred in summer 2022.

Based on information obtained from responsible party of resident #1 and complainant, disputed charge for excessive toilet flushing was reversed.

Unfounded

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: 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: 3 of 3