415600133-12-5-2023-14-AS-CFLH-CZDQWF-20240111113151

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600133
Report Date: 12/05/2023
Date Signed: 12/05/2023 04:35:58 PM

Unfounded

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
11/30/2023 and conducted by Evaluator Audrey Jeung

COMPLAINT CONTROL NUMBER: 14-AS-20231130164450

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: 82	DATE:	12/05/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Kirk Brooks		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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- Due to staff neglect, resident was physically assaulted and sustained a fracture
- Staff did not prevent resident from engaging in physical altercations with
another resident in care.
- Staff did not observe resident's change in mental status.
- Staff did not report incident to CCL

INVESTIGATION FINDINGS:

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LPA Jeung met with national operations specialist in the absence of executive director regarding incident that occured in October 2023. Video surveillance was viewed for 10/18/23 starting at 8:50 pm in the Life Guidance entry hallway. At 8:56 pm, client #1 fell as a result of interaction with client #2, which was initiated by client #1. Staff intervened prior to and immediately following client #1 fall.

Following this incident, client #2 needs were assessed by staff; Resident Functional Needs Assessment and Service Plan completed and reviewed with responsible party.

Incident of 10/18/23 was reported to CCLD via fax and confirmed.

These allegations are determined to be unfounded, meaning that the allegations could not have happened and/or are without a reasonable basis.

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: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

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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