Inspection Reports for Atria Park of San Mateo

The visit was an unannounced case management - legal/non-compliance inspection conducted in response to a Stipulation/Waiver/Order dated 11/29/2023.

The Licensing Program Analyst observed appropriate signage in food areas, proper posting of the stipulation, maintenance of cleaning and hazardous materials policies, and documentation of resident acknowledgements and staff training. No deficiencies were cited during the visit.

An unannounced annual inspection visit was conducted to evaluate the facility's compliance with licensing requirements.

The inspection found the facility to be in good condition with no deficiencies cited. Resident rooms, common areas, and safety equipment were all observed to be well maintained, and records for residents and staff were complete and up to date.

The visit was an unannounced case management - incident investigation conducted due to a report of a possible physical injury that occurred on 2025-04-09 involving resident R1 and staff S1.

The Licensing Program Analyst collected pertinent documents and information regarding the incident involving R1 and S1. The report was reviewed with the Life Guidance Director Lavendar Halafau, and a copy was provided during the visit.

The complaint involved a possible physical injury to resident R1 during servicing by staff S1 on 2025-04-09. The investigation was conducted on 2025-04-11.

Unannounced case management - legal/non-compliance visit conducted in response to and as per Stipulation/Waiver/Order dated 11/29/2023.

The visit confirmed documentation of administrator training on hazardous materials handling, emergency planning, staffing levels, and communication with emergency services. Documentation was also provided for staff training on responding to resident ingestion of hazardous materials and written acknowledgements from residents regarding receipt of stipulation and amended accusation. No deficiencies were cited.

An unannounced complaint investigation visit was conducted regarding allegations of unlawful eviction, failure to conduct resident reassessment, failure to provide services as per admission agreement, and medication error.

The investigation found that the eviction notice was valid and complied with licensing requirements, reassessments were conducted appropriately, the admission agreement contained necessary information and conditions, and medications were administered as prescribed. The complaint was determined to be unfounded and dismissed.

The complaint alleged unlawful eviction, failure to conduct reassessment of resident, failure to provide services in admission agreement, and medication error. The complaint was found to be unfounded and dismissed.

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No inspection report data or findings are present in the document.

An unannounced case management - legal/non-compliance visit was conducted in response to and as per Stipulation/Waiver/Order dated 11/29/2023.

The Licensing Program Analyst observed secure storage and proper labeling of cleaning compounds and poisons, appropriate signage regarding food and beverage containers, adequate staffing in the memory care unit, and posting of the Stipulation/Waiver/Order. No deficiencies were cited.

This was an unannounced complaint investigation visit triggered by a complaint received on 10/26/2023 regarding staff not answering the facility phone.

The allegation that staff did not answer the facility phone on 10/12/2023 from 11:30 pm for 2-3 hours was substantiated based on witness information and evidence of unanswered calls. The facility failed to ensure telephone communications were responded to promptly, posing a potential health, safety, or personal rights risk to clients.

The complaint was substantiated. The allegation was that staff did not answer the facility phone starting at 11:30 pm on 10/12/2023 for 2-3 hours. Evidence of unanswered calls was provided and reported to resident services director. Overnight staff were questioned but it is unknown if the overnight nurse was interviewed.

The visit was a Case Management - Legal/Non-compliance inspection conducted in response to a Stipulation/Waiver/Order dated 11/29/2023.

The administrator received documented training on hazardous materials handling, emergency planning, staffing levels, and communication with emergency services. Staff training on responding to residents ingesting hazardous materials was documented for quarters 1 and 2. Written acknowledgements from residents regarding receipt of the Stipulation and amended accusation were maintained. No deficiencies were cited.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not meet residents' hygiene and medical needs.

Based on review of facility records and interviews with staff and witnesses, the allegations were determined to be unsubstantiated due to insufficient evidence. Although staff failed to apply prescribed antibacterial ointment on several days, it could not be definitively proven that this contributed to infection.

The complaint alleged that staff did not meet residents' hygiene and medical needs. The investigation found these allegations unsubstantiated as there was not enough evidence to prove the alleged violations occurred.

The inspection was a required unannounced 1-year annual inspection to evaluate compliance with RCFE California Code of Regulations, Title 22, Division 6, Chapter 8.

No deficiencies were observed during the inspection. The facility is operating in substantial compliance. Some updated forms and information were requested to be submitted by 07/03/2024.

The visit was conducted as a Case Management - Legal/Non-compliance inspection in response to a Stipulation/Waiver/Order dated 11/29/2023.

The inspection found appropriate signage in food areas, posting of the Stipulation on the bulletin board, maintenance of cleaning and hazardous materials policies, written acknowledgements from residents regarding the Stipulation, and signed hazardous communication forms by staff. No deficiencies were cited.

A collaborative virtual meeting was conducted by the San Bruno and Oakland CCLD Adult & Senior Care Regional Offices and CCLD Counsel with representatives of Atria Park of San Mateo and Atria Walnut Creek to review the Stipulation Agreements dated 11/29/2023 and discuss their status and implementation.

The meeting involved discussion of stipulations and their implementation status, with questions and clarifications addressed. No specific deficiencies or violations were detailed in the report.

Unannounced complaint investigation visit conducted due to allegations of staff neglect resulting in physical assault and injury to a resident, failure to prevent altercations, failure to observe mental status changes, and failure to report incidents to the licensing authority.

Investigation included review of video surveillance and interviews; staff intervened appropriately during the incident, assessments and service plans were completed, and the incident was reported to the licensing authority. The allegations were determined to be unfounded with no reasonable basis.

Allegations included staff neglect causing physical assault and fracture, failure to prevent resident altercations, failure to observe mental status changes, and failure to report incidents to Community Care Licensing. The investigation found these allegations to be unfounded.

The visit was conducted in response to a Suspected Abuse Report submitted by the facility regarding client #1.

The licensing program analyst met with a national operations specialist who provided additional details of the incident observed on surveillance video. Additional information is to be obtained and no deficiency was cited.

Visit was complaint-related due to a Suspected Abuse Report. No deficiency was cited and further information is pending.

The visit was conducted as a Case Management - Legal/Non-compliance inspection in response to a Stipulation/Waiver/Order dated 11/29/2023.

The inspection found secure storage and proper labeling of cleaning compounds and poisons, appropriate signage regarding food and beverage containers, and adequate staffing in the memory care unit. No deficiencies were cited.

The inspection was conducted as a complaint investigation regarding client #1, who was admitted on 2023-08-19, to evaluate alleged deficiencies in medication administration and resident care.

The investigation found that staff failed to provide medications to the resident for 24 hours, including insulin, resulting in a medical emergency and intensive care hospitalization. Additionally, the facility LVN did not respond appropriately to the resident's condition when vomiting was observed, posing an immediate health and safety risk.

Complaint investigation was concluded and a report was delivered to the facility on 2023-10-10. The complaint involved failure to administer medications and inadequate response to resident's medical condition.

The inspection was an unannounced complaint investigation visit triggered by complaints received on 2023-08-22 regarding inadequate food service, unmet showering needs, lack of prescription orders for medications, and improper resident assessments prior to admissions.

The investigation determined the allegations to be unsubstantiated or unfounded. Reviews of staff schedules, interviews, and documentation showed no sufficient evidence of violations. One incident of medication oversight causing a medical emergency was reported, and involved staff were terminated.

The complaint investigation was unannounced and conducted by Evaluator Audrey Jeung. Allegations included inadequate food service, unmet showering needs, lack of prescription orders for medications, and improper assessments prior to admissions. The findings were unsubstantiated or unfounded. A medication administration error on 8/20/23 led to a medical emergency, reported to licensing, and resulted in termination of two staff members.

An unannounced complaint investigation was conducted following a complaint received on 2023-01-24 regarding allegations of inadequate resident care, physical abuse, and unwarranted charges at Atria Park of San Mateo.

The investigation found the allegations to be unsubstantiated or unfounded due to insufficient evidence. Staff were found to have provided hygiene, diapering, and hydration assistance, and no evidence of physical abuse or improper charges was found.

The complaint included allegations that staff did not meet residents' hygiene, diapering, and hydration needs, failed to respond to requests for assistance, were inadequately trained, and that residents sustained unexplained injuries/bruising. Additional allegations included physical abuse and charging residents for services not provided. The investigation determined these allegations to be unsubstantiated or unfounded due to lack of evidence and unavailable witnesses.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-12-16 regarding staff supervision of a resident.

The allegation that staff did not properly supervise a resident was determined to be unsubstantiated based on review of facility and client records and staff interviews. Staffing was found appropriate for the memory care unit residents during the incident.

The complaint alleged improper supervision of a resident. The investigation found insufficient evidence to prove the alleged violation occurred. The incident involved two memory care residents, with hourly status checks documented and no distress observed.

Unannounced complaint investigation visit conducted due to an allegation that staff does not ensure residents are transported to scheduled appointments in a timely manner.

The allegation was determined to be unsubstantiated based on review of client records, transportation schedules, and interviews with staff and clients. The facility employs a driver who transports residents on scheduled days, and no evidence was found that residents missed appointments due to untimely transportation.

The complaint alleged that staff did not ensure timely transportation of residents to scheduled appointments. The investigation found no sufficient evidence to substantiate the allegation.

The inspection was an unannounced complaint investigation triggered by an allegation of insufficient staffing to meet residents' needs received on 12/15/2022.

Based on review of staff schedules, surveillance video, and interviews, the allegation of insufficient staffing was determined to be unsubstantiated due to lack of sufficient evidence to prove the violation occurred.

The complaint alleged insufficient staffing on the night of 12/7/22, claiming only one staff was working. Investigation found 4 staff assigned to assisted living and 2 to memory care overnight. Staff responded to resident calls multiple times with varying response times. Resident could not recall calls or 9-1-1 on that date. The allegation was unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff failed to provide basic care services and other related complaints.

The investigation substantiated that staff failed to provide consistent dressing, undressing, and toileting assistance to a hospice resident, resulting in a deficiency citation. Other allegations related to failure to observe/report a coccyx sore, timely emergency response, and medication provision were found unsubstantiated.

The complaint investigation was substantiated for failure to provide basic care services including dressing and toileting assistance. Other allegations about failure to observe/report coccyx sore, emergency call response, and medication provision were unsubstantiated.

Unannounced complaint investigation visit conducted due to allegations that staff did not notify resident's responsible party of a change in condition and neglect resulting in a resident sustaining an unstageable pressure injury.

The investigation substantiated that staff failed to notify the resident's responsible party of a change in condition related to an unstageable heel wound, posing an immediate health and safety risk. However, the allegation of licensee neglect causing the pressure injury was unsubstantiated due to insufficient evidence.

The complaint investigation was substantiated regarding failure to notify the responsible party of a resident's condition change. The allegation of neglect causing the pressure injury was unsubstantiated.

The visit was conducted to follow up on a substantiated complaint alleging failure to observe residents’ personal rights, resulting in the death of two residents and serious bodily injuries to a third.

The investigation found that staff mistakenly served dishwashing detergent to residents, causing serious burns and resulting in the deaths of two residents and serious injury to a third. Multiple regulatory violations were cited related to personal rights, storage of hazardous materials, personnel competency, and administrator responsibilities. A civil penalty was assessed.

The complaint was substantiated. It involved failure to observe residents’ personal rights leading to death of two residents and serious bodily injury to a third due to ingestion of dishwashing detergent mistakenly served by staff.

The visit was a Case Management - Other type of unannounced inspection to confirm receipt and acknowledgment of the Department's accusations for license revocation, administrator de-certification, and staff exclusions.

No deficiencies were cited during the visit. The licensing analyst confirmed that written notice of the accusations was given to residents, responsible parties, and the local Ombudsman program.

An unannounced Case Management visit was conducted to deliver an amended report related to complaint number 14-AS-20220829165142, correcting immediate exclusion orders issued for residents S1, S2, S3, and S5.

The Licensing Program Analyst reviewed and discussed the amended report with the Resident Service Director, providing a copy of the report during the visit and electronically afterward.

The visit was in reference to complaint number 14-AS-20220829165142 and involved correction of immediate exclusion orders for specific residents.

An unannounced complaint investigation visit was conducted due to a complaint received on 08/29/2022 alleging that three residents ingested poison while in care resulting in serious injury and/or death.

The investigation found that facility staff negligently left a pitcher of dishwashing detergent accessible to residents, which was served to three residents causing serious burns and resulting in the deaths of two residents. Immediate exclusion orders were issued for four staff members involved, and civil penalties were assessed.

The complaint was substantiated. Three residents ingested dishwashing detergent resulting in serious bodily injuries and deaths of two residents. The investigation included interviews, review of records, video footage, medical and police reports. Immediate exclusion orders were issued for staff S1, S2, S3, and S5. A civil penalty of $500 was assessed immediately, with additional penalties pending review.

Unannounced complaint investigation visit conducted in response to allegations received on 09/07/2022 regarding staff failing to observe and report changes in resident condition, failure to obtain medical intervention, and staff conduct issues.

The investigation found that the facility staff documented and reported changes in the resident's condition appropriately and communicated with the physician as required. Interviews with staff, residents, and responsible parties indicated no substantiated evidence of disrespectful or rough handling by staff. Therefore, all allegations were unsubstantiated.

The complaint involved multiple allegations including failure to observe and report changes in resident condition, failure to obtain medical intervention, and staff being disrespectful and rough with clients. The investigation concluded these allegations were unsubstantiated due to lack of preponderance of evidence.

The visit was a case management inspection to evaluate the facility's compliance with regulations related to client rights and safety, including inspection of door locking mechanisms and access to personal toiletries.

The licensing program analyst met with facility staff and inspected the locking mechanisms of doors in the Life Guidance unit. It was confirmed that clients have the right to access personal toiletries unless restricted by a physician's written order. No deficiencies were cited during this case management visit.

The inspection visit was conducted as a complaint investigation to evaluate deficiencies related to regulatory compliance.

During the complaint investigation, a deficiency was observed regarding the failure to maintain criminal record clearance for a former staff member, which posed an immediate health, safety, and personal rights risk.

The visit was complaint-related, and the deficiency observed was substantiated as a failure to maintain required criminal record clearance for a staff member.

An unannounced annual required 1-year inspection focused on COVID infection control and general compliance was conducted.

The inspection found that infection control practices were generally followed, PPE supplies were adequate, and fire safety equipment was properly maintained. However, one staff member (S1) did not have a current criminal record clearance, which poses an immediate risk. A civil penalty of $300 was assessed.

The visit was a case management follow-up to deliver Facility Evaluation Reports and Complaint Investigation Reports that could not be delivered earlier due to technical difficulties.

No deficiencies were cited during this visit. An Order of Immediate Exclusion for staff #1 was given to the administrator pertaining to an incident on 11/15/22.

An unannounced complaint investigation visit was conducted in response to a complaint received on 07/27/2022 regarding a questionable death at the facility.

The investigation included interviews and record reviews related to a client who was hospitalized and later expired. The allegation of questionable death was determined to be unsubstantiated due to insufficient evidence to prove the alleged violation did or did not occur.

The complaint involved an allegation of a questionable death. The investigation found no evidence of staff observing injuries or falls, and the death was ruled accidental by the Coroner's Report. The allegation was unsubstantiated.

An unannounced complaint investigation visit was conducted following a complaint received on 07/01/2021 alleging that staff did not groom a resident.

The investigation found that Monthly Assignment Reports documenting completion of grooming and other care tasks for the resident were not available for review. The allegation was determined to be unsubstantiated due to insufficient evidence to prove the violation occurred.

The complaint was unsubstantiated based on information obtained from staff and facility records. Although the allegation may have occurred or be valid, there was not enough evidence to prove the alleged violation did or did not occur.

This was an unannounced complaint investigation visit triggered by allegations received on 09/23/2022 regarding inappropriate staff behavior and misuse of resident funds.

The investigation included interviews with staff and review of staff files. The allegations were determined to be unfounded, meaning they could not have happened or lacked a reasonable basis.

Allegations included staff having an inappropriate relationship with a resident and staff using resident funds to acquire property. The complaint was investigated and found to be unfounded.

The visit was conducted in response to multiple incident reports dated 11/15/22, 11/18/22, 11/22/22, and 10/27/22 involving clients and staff at the facility.

A deficiency was cited related to failure to ensure that a caregiver (Staff #2) had the required criminal record clearance prior to working at the facility, posing an immediate health, safety, or personal rights risk to clients.

The visit was complaint-related, triggered by incident reports involving multiple clients and staff. The deficiency cited was based on an incident report dated 10/27/22.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-07-01 regarding allegations of inadequate resident care and facility conditions.

The investigation substantiated that staff failed to provide adequate bathing assistance to a resident as specified in the care plan. Other allegations including resident injury, bathroom cleanliness, laundry service, bed linen provision, and safeguarding of personal belongings were determined to be unsubstantiated due to insufficient evidence.

The complaint included allegations that staff did not bathe the resident, resident sustained injury while in care, bathroom was not maintained clean and sanitary, staff did not provide basic laundry service or clean bed linen, and staff did not safeguard resident's personal belongings. The bathing allegation was substantiated; other allegations were unsubstantiated.

Unannounced complaint investigation visit conducted in response to allegations that a resident sustained multiple pressure injuries while in care and that staff did not ensure a resident was eating accordingly.

The investigation determined the allegations to be unsubstantiated after reviewing facility and medical records and interviewing staff and medical providers. The resident had pre-existing conditions and received appropriate care including wound treatment and dietary adjustments, but developed pressure ulcers and weight loss due to health conditions. There was insufficient evidence to prove the alleged violations occurred.

The complaint was unsubstantiated based on investigation findings. The allegations involved pressure injuries and inadequate nutritional care, but evidence did not support violations.

The inspection was an unannounced complaint investigation triggered by a complaint received on 2022-08-05 regarding facility staff not following Covid-19 safety protocols.

The investigation substantiated the allegation that PPE including N95 respirators, gowns, gloves, and donning and doffing instructions were not properly maintained in isolation carts outside client apartments with COVID-positive residents, posing an immediate health, safety, and personal rights risk to clients.

The complaint was substantiated based on investigation and observations made on 2022-08-12. The preponderance of evidence standard was met.

An unannounced Health and Welfare Check inspection was conducted to assess the facility's compliance with health and safety standards.

The Licensing Program Analyst and Investigator toured the facility and grounds, observed the kitchens, and found no citations were issued during this visit.

The visit was conducted in response to an incident report of client elopement on 2022-06-07, involving a case management incident investigation.

An internal investigation was conducted by the resident services director, and retraining was provided to the receptionist on duty at the time of the incident. The Licensing Program Analyst requested copies of training records and written procedures for the front desk receptionist. No deficiencies were issued during this visit.

The visit was triggered by a complaint related to a client elopement incident on 2022-06-07. The complaint was investigated, and no deficiencies were found or issued.

The visit was conducted in response to an incident report dated 08/14/2021 regarding the elopement of a resident. The licensing program analyst met with facility staff to obtain additional details and review procedures related to the incident.

The analyst reviewed the resident's file, observed the rooms involved, and assessed staff responsibilities related to the alarm response. The facility plans to implement new processes to prevent recurrence and submit an addendum to the incident report within five business days.

Visit was triggered by an incident report of resident elopement dated 08/14/2021. No substantiation status explicitly stated.

The visit was a Case Management - Other type of unannounced inspection to evaluate facility compliance, including COVID-19 related requirements.

The facility lacked adequate COVID reminder signs for wearing face coverings and maintaining social distance, despite having an informational COVID sign in the entry foyer. It was strongly advised that the facility post individual reminder signs for face coverings, social distancing, and covering nose and mouth when coughing or sneezing.

The inspection was a required unannounced 1-year visit to evaluate compliance with regulations for the facility.

The facility was toured and infection control practices, safety, and environmental conditions were reviewed. A deficiency was cited related to criminal record clearances for two staff members who have client contact but whose clearances were not associated with the facility.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 12/14/2020 regarding staffing sufficiency, staff qualifications, resident assessment after falling, and treatment of residents with dignity and respect.

The investigation found that the facility had sufficient staff and qualified personnel as required by regulations. There was insufficient evidence to substantiate allegations related to improper resident assessment after a fall and failure to treat residents with dignity and respect. Overall, the allegations were unsubstantiated.

The complaint included allegations that the facility lacked sufficient staff, staff were not qualified, a staff member did not properly assess a resident after falling, and a staff member did not treat a resident with dignity and respect. The investigation concluded all allegations were unsubstantiated due to lack of evidence or regulatory requirements not being violated.

The visit was an unannounced case management virtual visit conducted during the investigation of complaint 14-AS-20200520143002 regarding a resident who developed a stage 3 pressure wound, a prohibited health condition.

The licensee failed to request an exception to retain the resident and failed to provide a higher level of care despite communication from the home health nurse about the resident's worsening condition. The licensee did not ensure proper care by failing to follow wound care instructions and the Administrator did not fulfill qualifications and duties during the period of 04/18/20 through 04/24/20.

Investigation of complaint 14-AS-20200520143002 found preponderance of evidence that the licensee failed to ensure proper care of the resident with a stage 3 pressure wound and failed to act on worsening condition communicated by the home health nurse.

An unannounced complaint investigation visit was conducted in response to an allegation that a resident sustained a stage 4 pressure injury while in care.

The investigation found that the facility failed to provide necessary higher level care and 1:1 attention to a resident whose wound progressed from Stage 2 to Stage 4, resulting in serious injury. The allegation was substantiated based on medical records, staff and medical interviews.

The complaint was substantiated. The allegation that a resident sustained a stage 4 pressure injury while in care was found valid based on the preponderance of evidence.

An unannounced complaint investigation visit was conducted in response to a complaint received on 2020-12-07 regarding the facility's compliance with the admission agreement.

The investigation found that the admission agreement for Resident 1 was tentative pending physician report and medical records, which revealed that Resident 1 required a higher level of care than the facility could provide. No payment was made for Resident 1's admission. The allegation was deemed unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that the facility did not comply with the admission agreement. The allegation was unsubstantiated after investigation.

An unannounced complaint investigation was conducted in response to allegations that staff were not meeting residents' medical needs and not transporting residents to appointments.

The investigation found documentation and staff interviews supporting that medical appointments were attended and transportation was provided as alleged. Therefore, the allegations were deemed unsubstantiated.

The complaint was unsubstantiated based on review of medical records, appointment schedules, transportation logs, and staff interviews indicating residents attended medical appointments and were transported as required.