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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600133
Report Date: 06/19/2024
Date Signed: 06/19/2024 07:06:03 PM


Document Has Been Signed on 06/19/2024 07:06 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:ATRIA PARK OF SAN MATEOFACILITY NUMBER:
415600133
ADMINISTRATOR:NELSON RODRIGUESFACILITY TYPE:
740
ADDRESS:2883 S NORFOLK STTELEPHONE:
(650) 378-3000
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:175CENSUS: 75DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Kirk BrooksTIME COMPLETED:
07:00 PM
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LPA Audrey Jeung toured facility and grounds, consisting of 135 studios and 1-bedroom units on 3 floors. Thirty rooms comprise the memory care unit on the ground floor, where there are 4 exits--each equipped with a delayed egress. This unit has a dining room, activity area and living room, as well as a prep kitchen and enclosed patio. There are an additional 15 units on the ground floor, 45 units on the 2nd floor, 45 units on the 3rd floor for independent and assisted living residents. All living units include a private bathroom, and refrigerators, mini microwave ovens, wet bars, and wall safes are present in all assisted living units. A large dining room, roof top open air terrace and multiple common use rooms are available to independent and assisted living resident, including a fitness room. Rooms were inspected randomly. No accessible bodies of water or fire safety hazards observed. Two day perishable and 7 day non-perishable food supplies are maintained, and PPE supply is adequate. Copies of registered dietician consultation reports dated 3/18/24 and 6/14/24 are given to LPA. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Hot water temperature is tested at 105 degrees in 2nd and 3rd floor units. Liquid soap is available in common bathrooms and private bathrooms of independent and assisted living bathrooms, but not in memory care bathrooms, for the safety of memory care residents.
First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is accessible. Some client records are reviewed. Due to time constraints, medications review is not done.
Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, and required staff records are maintained.

Kirk Brooks is a certified RCFE administrator (x 1/26) that oversees facility operations.

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SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ATRIA PARK OF SAN MATEO
FACILITY NUMBER: 415600133
VISIT DATE: 06/19/2024
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The following updated forms/information are requested to be submitted to CCLD BY 7/3/24:
• LIC 9282 Infection Control Plan (signed and dated)
• LIC 309 Administrative Organization
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan (signed and dated)
• Proof of current Liability Insurance

No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed.
Facility is operating in substantial compliance.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
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