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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600133
Report Date: 08/19/2021
Date Signed: 08/19/2021 02:28:06 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 MATEOFACILITY NUMBER:
415600133
ADMINISTRATOR:CECILIA DAUTHFACILITY TYPE:
740
ADDRESS:2883 S NORFOLK STTELEPHONE:
(650) 378-3000
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:175CENSUS: 90DATE:
08/19/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Cecilia DauthTIME COMPLETED:
02:30 PM
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During facility walk through, LPA Jeung observed that there are no COVID reminder signs to wear face coverings and maintain social distance. This was discussed with maintenance director on 7/9/21 during annual inspection. CDC and CCLD guidance has been issued mandating face coverings indoors. Facility has a COVID sign in the entry foyer--8 1/2" x 11'--to Stop the Spread of Germs, which states to get a vaccine, cover cough or sneeze, maintain 6 foot distance, wear a mask, do not touch eyes, nose, mouth, clean and disinfect surfaces and objects, stay home when you are sick, and wash your hands. This sign does not adequately serve as a reminder for staff and residents to wear a face covering, maintain social distancing, cover nose and mouth when coughing or sneezing, as it is more for informational purposes.

It is strongly advised that facility prominently post individual signs that serve as reminders for persons to wear face coverings, maintain social distance, and cover nose and mouth when coughing or sneezing.

The CA Dept. of Social Services has issued the following Provider Information Notices (PINs) to notify providers about current COVID requirements:
- PIN 21-17.2-ASC dated 5/14/21
- PIN 21-32.1-ASC dated 8/11/21
- PIN 21-38-ASC dated 8/19/21
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
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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