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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600133
Report Date: 09/17/2024
Date Signed: 09/17/2024 12:39:32 PM


Document Has Been Signed on 09/17/2024 12:39 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:BROOKS, THOMAS KIRKFACILITY TYPE:
740
ADDRESS:2883 S NORFOLK STTELEPHONE:
(650) 378-3000
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:175CENSUS: 76DATE:
09/17/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Kirk BrooksTIME COMPLETED:
12:45 PM
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In response to and as per Stipulation/Waiver/Order dated 11/29/23, LPA Jeung observed the following:

1. Documentation that administrator received 25 hours of live virtual training and 15 hours of online self-study in January and February 2024 from a local vendor approved by CDSS Administrator Certification Unit on:
a. Proper handling of hazardous materials, including how to store, who can/should handle, how to identify, how to dispense, and how to catalogue hazardous materials.
b. Emergency planning, including methods for ensuring that every substitute administrator is prepared to function as an administrator, methods to ensure that staff are aware of their roles in an emergency, what role Poison Control has in emergencies.
c. Facility staffing levels/resource allocation, including creation of staffing schedules to have the appropriate level of staffing at all times.
d. Communication with emergency services, including development of a system and incident command process in the event of an emergency and clear assignment of communication between staff and emergency responders, as well as the importance of disseminating correct and truthful information to emergency responders.

2. Documentation of quarters 1 and 2 of 9 staff who were trained on how to respond when a resident ingests a cleaning product or other hazardous material.

3. Written acknowledgements of new and current residents that they have received copies of Stipulation and amended accusation are maintained.

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: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
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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