415600133-7-9-2021-14-AS-AJEG-C4S4HQ-20210709190731

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600133
Report Date: 07/09/2021
Date Signed: 07/09/2021 07:07:37 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	ATRIA PARK OF SAN MATEO		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: 87	DATE:	07/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Igor Protich		TIME COMPLETED:	07:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	LPA Audrey Jeung toured facility and grounds, consisting of 135 studios and 1-bedroom units on 3 floors. Thirty rooms comprise the memory care unit on the ground floor, where there are 4 exits--each equipped with a delayed egress. This unit has a dining room, activity area and living room, as well as a prep kitchen and enclosed patio. There are an additional 15 units on the ground floor, 45 units on the 2nd floor, 45 units on the 3rd floor for independent and assisted living residents. All living units include a private bathroom. A large dining room, roof top open air terrace and multiple common use rooms are available to independent and assisted living resident, including a fitness room. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Liquid soap is available in common bathrooms and private bathrooms of independent and assisted living bathrooms, but not in memory care bathrooms, for the safety of memory care residents. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Cecilia Dauth is a certified RCFE administrator (x 3/22) that oversees facility operations. The following updated forms/information are requested to be submitted to CCLD BY 7/16/21: • LIC 308 Designation of Administrative Responsibility • LIC 309 Administrative Organization • LIC 500 Presonnel Report • LIC 610E Emergency Disaster Plan (revised) • Proof of current Liability Insurance Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ATRIA PARK OF SAN MATEO	FACILITY NUMBER: 415600133
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(c)(1-2)

A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: (1) A signed Criminal Background Clearance Transfer Request, LIC 9182 (Rev. 4/02). (2) A copy of the individual's: (A) Driver's license, or (B) Valid identification card issued by the Department of Motor Vehicles, or (C) Valid photo identification issued by another state or the United States government if the individual is not a California resident.
	Deficient Practice Statement
1 2 3 4	Based on review of Licensing Information System, the licensee did not comply with the section cited above, as 2 staff present during LPA's visit have client contact and criminal record clearances are not associated to facility, which poses an immediate health, safety or personal rights risk to persons in care. Staff I.P. is maintenance director and criminal record clearance is not transferred to this facility. He has been employed for 19 months. There is no criminal record informatiion on file for agency LVN K.E. She has been employed for 10 days and has direct contact with residents,
	POC Due Date: 07/09/2021
	Plan of Correction
1 2 3 4	Criminal record clearance transfer requests for staff I.P. and agency LVN K.E. are given to LPA today. Deficiency corrected and cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC809 (FAS) - (06/04)

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