415600133-3-22-2021-14-AS-KHOS-BZLJSG-20210330071820

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600133
Report Date: 03/22/2021
Date Signed: 03/22/2021 09:42:29 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/07/2020 and conducted by Evaluator Bertha Raygoza

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20201207104912

FACILITY NAME:	ATRIA HILLSDALE		FACILITY NUMBER:	415600133
ADMINISTRATOR:	PERRYMAN, DAVID		FACILITY TYPE:	740
ADDRESS:	2883 S NORFOLK ST		TELEPHONE:	(650) 378-3000
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	175	CENSUS: 92	DATE:	03/22/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Cecilia Dauth, Administrator & April Bennett, Staff In Charge		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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9

- Facility did not comply with admission agreement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Raygoza made a subsequent virtual complaint visit on the above allegation and met with Staff In Charge, April Bennett via FaceTime. LPA Raygoza stated the purpose of visit.

- Facility did not comply with admission agreement. During the Investigation the following came forth, the Admission Agreement for R1 was tentative on Physician report and medical records. Medical records revealed that R1 was a higher level of care and the facility could not meet the needs of R1. There was no payment made for admission for R1. The allegation was deemed unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated at this time.

This report was reviewed and discussed with Cecilia Dauth, Administrator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha Raygoza	TELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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