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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600133
Report Date: 07/29/2022
Date Signed: 07/29/2022 06:29:38 PM


Document Has Been Signed on 07/29/2022 06:29 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:ATRIA PARK OF SAN MATEOFACILITY NUMBER:
415600133
ADMINISTRATOR:JENNIFER DUENASFACILITY TYPE:
740
ADDRESS:2883 S NORFOLK STTELEPHONE:
(650) 378-3000
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:175CENSUS: 92DATE:
07/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Shanel ThitphanethTIME COMPLETED:
06:30 PM
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In response to Incident Report of client elopement on 6/7/22, LPA Jeung reviewed client file and obtained copies of relevant documents.
As per resident services director, an internal investigation was conducted. According to Incident Report, receptionist on duty at the time was provided with retraining.
LPA requested that copies of training records be sent to LPA with written procedures or job description of front desk receptionist. LPA observed a binder at the front desk, including list of "residents unable to leave unassisted," dated 7/28/22. Ms. Thitphaneth advised that this list is updated as necessary.

No deficiency issued today.

SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
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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