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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 07:03:49 PM


Document Has Been Signed on 06/19/2024 07:03 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:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kirk BrooksTIME COMPLETED:
07:00 PM
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In response to and as per Stipulation/Waiver/Order dated 11/29/23, LPA Jeung observed the following:

1. Appropriate signage in main and LG kitchen and dining rooms that food and beverage containers can only be used for food and beverages
2. Stipulation is posted on bulletin board on ground level hallway outside of main dining room.
3. Cleaning and Hazardous Materials Policies and Procedures manual is maintained in copy room near receptionist.
4. Written acknowledgements of new and current residents that they have received copies of Stipulation and amended accusation are maintained.
5. Hazardous Communication Review & Acknowledgement forms are observed signed by 10 staff.

Mr. Brooks acknowledges conditions of Stipulation, including additional staff training and reporting requirements.

No deficiency cited.
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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