415600133-10-18-2024-14-AS-ACON-DABTFS-20241023144155

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600133
Report Date: 09/17/2024
Date Signed: 10/18/2024 10:12:37 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
10/26/2023 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20231026130636

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: 76	DATE:	09/17/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Kirk Brooks and Kris Waluszko		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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- Staff did not meet resident's hygiene needs
- Staff did not meet resident's medical needs

INVESTIGATION FINDINGS:

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------ This is an amended report ---------
LPA Jeung interviewed staff.

Based on review of facility records and interviews with staff and witnesses, these allegations are determined to be unsubstantiated. Although the allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations did or did not occur.

Former Life Guidance client #1 was provided with a private duty aide from 8 am to 8 pm for approximately 2 months from late September through November 2023. While there is evidence that the private aide assisted client with personal care, facility staff continued to provide stand-by assistance with grooming tasks twice a day, per staff initials on facility's Resident Monthly Assignment Reports, which included oral care. Despite the presence of a private duty aide, facility staff are responsible for providing care identified in the Resident Functional Needs Assessment and Service Plan. It cannot be demonstrated that care provided by non-facility staff and/or facility staff contributed to client developing mouth sores.
Continued on next page

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20231026130636

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/17/2024

NARRATIVE

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Continued--

Former client was prescribed an antibacterial ointment to be applied at least once daily. According to facility's Medication Administration Records for September and October 2023, staff failed to apply the ointment 14 out of 28 days in September and 4 out of 29 days in October. Staff documented that client refused or reported no skin abnormalities on days when ointment was not applied. It is alleged that failure to apply the ointment daily resulted in an infection, or contributed to the infection, but this cannot be proven definitively.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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