Pricing ranges from
    $4,495 – 9,095/month

    Atria Park of San Mateo

    2883 S Norfolk St, San Mateo, CA, 94403
    • Independent living
    • Assisted living
    • Memory care
    AnonymousLoved one of resident
    4.0

    Caring staff, good but inconsistent

    I placed my mom here and overall I'm pleased - the staff are genuinely caring and attentive, the building is bright, clean and recently remodeled, and there are lots of amenities and activities. Move-in and communication were smooth, but housekeeping and laundry can be inconsistent. Dining gets mixed reviews (great chef some days, hit-or-miss others). Apartments are nice but small with no kitchen, and costs/billing can be high/uncertain. Good choice for active seniors; I'd recommend with caution for advanced dementia or heavy care needs.

    Pricing

    $4,495+/moStudioAssisted Living
    $5,995+/mo1 BedroomAssisted Living
    $7,095+/moSemi-privateMemory Care
    $9,095+/moSuiteMemory Care

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Coordination with health care providers
    • Hospice waiver
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Spa
    • Telephone
    • Wifi

    Memory care community services

    • Dementia waiver
    • Mild cognitive impairment
    • Specialized memory care programming

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (medical)
    • Transportation arrangement (non-medical)
    • Transportation to doctors appointments

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    4.12 · 154 reviews

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      4.0
    • Staff

      4.3
    • Meals

      3.9
    • Amenities

      3.8
    • Value

      2.5

    Pros

    • Warm, caring, and attentive caregiving staff
    • Staff who learn residents' names and provide personalized attention
    • Engage Life/activities program led by a highly praised director (Angie Serraon)
    • Wide variety of daily activities (bingo, movies, games, arts & crafts, outings)
    • Regular exercise classes (including twice-daily offerings)
    • Frequent social events and themed/holiday programming
    • On-site amenities: bistro, hair salon, movie theater, library, terrace/rooftop
    • Clean, well-maintained, recently remodeled/upscale appearance
    • Restaurant-style dining with varied menus and fresh items reported
    • Supportive dining staff and chefs noted by multiple reviewers
    • Shuttle service for medical appointments and shopping
    • 24-hour security, Life Alert system, and on-site nursing/RN presence
    • Compassionate med techs and caregiving teams praised repeatedly
    • Helpful and professional admissions/sales staff (no-pressure tours)
    • Family involvement welcomed and encouraged in activities
    • Safe location on the Peninsula and convenient access (e.g., near 101/Hillsdale)
    • Many reviewers report a home-like, family atmosphere
    • Good housekeeping and generally immaculate public areas
    • Transportation provided for outings and errands
    • Flexible or open dining hours in many reports
    • Bistro and snack options available during the day
    • Active, social community with strong resident engagement
    • Some reviewers note good value or reasonable pricing for services
    • Prompt emergency response and medical attention in many cases
    • Memory-care apartments and some dementia programming received positive mentions
    • Smaller-scale, comfortable apartment options (studios/one-bedrooms)
    • Helpful support with benefits paperwork (e.g., VA) and paperwork assistance
    • Positive move-in experiences and attentive follow-up by some managers
    • Festive decorations and strong activity-team energy
    • Multiple reviewers would recommend the community

    Cons

    • High staff turnover and understaffing reported frequently
    • Poor staff communication and lack of continuity of care
    • Medication errors, delayed meds, or incorrect medication lists
    • Inconsistent or poor management responsiveness and billing issues
    • Serious safety incidents reported (falls/hip fracture) and alleged negligence
    • Allegations of gross negligence, widely cited citations, and lawsuits (reported by reviewers)
    • Infection issues/outbreaks reported (e.g., scabies) in some accounts
    • Memory-care security concerns: escapes, wandering, sheriff involvement
    • Perception that memory-care residents can be treated as second-class
    • Some reports of unqualified or uncaring staff in specific incidents
    • Dining quality inconsistent: reports of cold, unappetizing, or meat-heavy meals
    • Slow or inadequate dining service at times (few servers, slow waitstaff)
    • Small apartment sizes, especially studios; lack of in-room kitchen or coffee area
    • Bathrooms not ADA-compliant in some units; accessibility/doorway issues
    • Limited outdoor space and busy/street-noise/parking challenges
    • Laundry delays, misplaced items, and occasional housekeeping lapses
    • Restrictions or policies causing denied returns after hospital stays
    • Policies limiting aides (e.g., not allowed to apply medication) and bed rail restrictions
    • Occasional odors (urine/death) reported on specific floors
    • Administration turnover and unclear leadership in some reviews
    • Extra fees, price increases, and perceived nickel-and-dime charges
    • Promised services sometimes not delivered (e.g., paid but services missing)
    • Room readiness and maintenance issues (broken locks, doorknobs falling off)
    • Some reviewers report poor customer service or rude front-desk interactions
    • Inadequate one-on-one care for higher-dependency residents
    • No skilled nursing/limited on-site skilled nursing services
    • Mixed reports about suitability for dementia residents (confusing layout)
    • Allegations of theft or criminal activity in a few reports (claimed by reviewers)
    • Some reviewers found the community overwhelming or too large for dementia needs

    Summary review

    Overall sentiment across the reviews for Atria Park of San Mateo is mixed but leans positive in many areas: reviewers consistently praise the frontline caregiving teams, the activities program, and the facility’s presentation and amenities. The most frequently noted strengths are warm, attentive staff who learn residents’ names and deliver personalized touches; a robust Engage Life activities schedule (with many specific mentions of Director Angie Serraon and her team); and an upscale, well-maintained campus that includes a bistro, hair salon, movie theater, rooftop terrace, library, and regular outings. Many families note prompt emergency response, a restaurant-style dining experience, and a genuine sense of community — residents taking part in frequent social events, holiday programming, and daily exercises. Admissions and sales staff are often described as professional and low-pressure, and multiple reviews highlight helpful services like shuttle transportation and assistance with VA paperwork.

    Care quality is a recurring theme with both strong positive and notable negative reports. Numerous reviewers describe compassionate med techs, attentive caregivers, and organized medication management in many cases, while others report concerning lapses: delayed or incorrect medications, inconsistent communication about care plans, and specific safety incidents (including a hip fracture and at least one report alleging gross negligence). Several reviews describe excellent one-on-one dementia support and thorough care coordination; conversely, there are multiple accounts of high staff turnover, understaffing, and lack of continuity that leave families without a consistent "go-to" person. Memory care opinions are particularly mixed — memory-care apartments and programming receive praise for atmosphere and décor in some reviews, yet other reviewers report escapes, wandering, sheriff involvement, and perceptions that memory-care residents receive less attention or are treated as second-class.

    Facilities and amenities are often singled out positively: many reviewers call the building upscale, clean, freshly remodeled, and hotel-like, with well-kept grounds and attractive common areas. The on-site amenities (bistro, movie theater, salon, gym, rooftop terrace) are frequently cited as community highlights that support socialization and quality of life. That said, several practical concerns reoccur: many units—especially studios—are described as small with no kitchenette or coffee area, and some bathrooms are not ADA-compliant or have awkward door swing/space issues for wheelchair users. Outdoor space and parking are limited in places, and construction or remodeling activity at times has been disruptive.

    Dining receives polarized feedback. A large group of reviewers praise the kitchen, fresh items in the bistro, chef attentiveness, and restaurant-style service with varied menus and special events like ice-cream socials. Simultaneously, other reviewers report cold or unappetizing meals, slow or inattentive waitstaff on occasion, meat-heavy menus with limited vegetarian options, and inconsistent food quality. Overall the dining experience appears to vary by meal period and staffing, with a strong core of positive reports but enough negative accounts to warrant caution.

    Management, communication, and business practices show notable variability in reviewer experiences. The sales and admissions staff frequently receive positive reviews, and some families report excellent follow-up from executive leadership. However, a recurring theme is inconsistent responsiveness from administration: billing disputes, delayed refunds, unexpected fees, price increases, and insufficient follow-through on promised services appear across multiple reports. There are also several serious, though less common, allegations in the reviews — reports of citations for care problems, litigation or impending lawsuits, claims of overmedication or neglect, and even allegations of criminal activity or poisoning. These more severe accusations are not the majority impression but are serious enough that prospective families should investigate further and ask for inspection/citation history and detailed safety records.

    Patterns and recommendations: prospective residents and families are likely to find Atria Park of San Mateo attractive for its activities program, social atmosphere, and many on-site amenities, especially if they value an active, upscale community and personalized everyday caregiving. If considering Atria, families should proactively interview staff about turnover and continuity plans, ask specific questions about medication management protocols, staffing ratios (especially in memory care), and recent health/safety citations. Inspect apartment layouts for ADA compliance and space needs, clarify all fees and refund policies in writing, and ask for references about memory care and any past incidents. Finally, visit during meal service and activities to evaluate food quality and programming firsthand. The reviews indicate a community with strong positives in staff warmth, social programming, and facilities, tempered by recurring operational concerns around communication, staffing stability, medication management, and a small number of serious safety or legal allegations that merit direct verification.

    Location

    Map showing location of Atria Park of San Mateo

    About Atria Park of San Mateo

    Atria Park of San Mateo sits about 20 minutes from downtown San Francisco, providing a senior and assisted living community where staff and residents know each other by name and share a sense of community, and when you walk in, the place feels clean with fresh air and friendly faces always seem to be around. The community offers different kinds of care such as independent living for active adults, assisted living for those who want some help with daily life, memory care for folks living with Alzheimer's or other forms of dementia in their secure Life Guidance® neighborhood, and even a skilled nursing facility onsite for residents needing more hands-on medical care, and all these areas are licensed with number 415600133, which gets checked twice a year.

    The Activity Director plans events, and there's a daily Engage Life® program plus The Social Series holds things like outdoor parties or book swaps, so there's always something folks can join to stay busy or meet neighbors, and there's a wellness center right inside the building for checkups and health monitoring, as well as a nurse available on-site at all hours in case anyone needs medical help or support, which can include things like diabetes help, vital signs checks, mealtime monitoring, injections, catheter or ostomy care, and even oxygen or nebulizer use-all for an extra fee. Memory care residents enjoy a structured environment with an open layout, a secure courtyard for fresh air, and regular social activities to encourage connection and movement.

    Residents can pick from a range of apartments, including private and shared rooms, companion suites, studios, or one-bedroom units, and every room is handicap accessible, with a walk-in shower and Wi-Fi, plus there's space for pets since the community is pet friendly, and folks with cars have resident parking available too. For dining, a chef offers wholesome meals made from fresh, seasonal ingredients, served in a dining room or at the on-site café with free refreshments, so those wanting a good meal each day have options. The housekeeping and laundry services help keep apartments tidy, and scheduled transportation takes residents to nearby restaurants, shops, or medical appointments for those who want or need to get out and about.

    Atria Park of San Mateo has many spaces where residents gather-such as a fitness center, salon, arts and crafts room, library, wellness center, business center, games room, bistro, patios, and worship space-so people can read, exercise, meet for cards, or get haircuts, and there's always a chance to pick up a hobby or make a friend. The Memory Care Neighborhood stays secure but open, letting memory care residents access a gated courtyard and enjoy programs designed to support their needs. The facility is known locally for staff who help cheerfully and treat people kindly, and the routines here try to promote good health and well-being rather than only meeting basic needs, all while staying verified and up-to-date with licensing so families know reviews happen often for protection and peace of mind.

    About Atria Senior Living

    Atria Park of San Mateo is managed by Atria Senior Living.

    Atria Senior Living, founded in 1996 and headquartered in Louisville, Kentucky, is one of North America's largest senior living providers, operating more than 230 communities across 38 U.S. states and seven Canadian provinces. Serving approximately 35,000 residents and employing over 10,000 staff members, Atria has grown from managing 20 communities to become a leader in the senior living industry with over $1.3 billion in revenue under management.

    The company offers a comprehensive range of care options including independent living, assisted living, memory care, and short-term stays through multiple brands: Atria Senior Living, Holiday by Atria, Atria Retirement Canada, Atria Signature Collection, and Coterie Senior Living (a joint venture with Related Companies). Their communities are particularly concentrated along the east and west coasts, with significant presence in major metropolitan areas including New York, California, Toronto, Boston, Houston, Atlanta, Dallas, Seattle, and Portland.

    Atria's philosophy centers on their belief that "People belong together®," emphasizing connection and creating homes where residents can thrive regardless of their care needs. Their signature Engage Life® program provides daily opportunities for residents to learn, socialize, stay fit, and achieve personal goals. Since 2004, Atria's pioneering Quality Enhancement program has set industry standards through bi-annual unannounced audits, focusing on both clinical excellence and resident experience.

    The company's commitment to excellence has earned widespread recognition, including over 120 prestigious industry awards in 2023 alone. Notably, 49 communities received top-tier recognition awards – more than any other senior living provider nationwide. Since 2018, Atria communities have averaged less than one deficiency per state survey, demonstrating their consistent dedication to quality care and regulatory compliance. This award-winning approach, combined with their innovative in-house marketing and comprehensive employee recognition programs, positions Atria as a trusted leader in senior living solutions.

    People often ask...

    State of California Inspection Reports

    81

    Inspections

    17

    Type A Citations

    4

    Type B Citations

    5

    Years of reports

    16 Jul 2025
    Found compliance with the stipulation terms, including proper signage, policies, resident acknowledgments, and hazard communication training; no deficiencies were found.
    • § 9058
    11 Apr 2025
    Investigated an allegation of possible physical injury involving R1 and S1 during servicing on 04/09/2025.
    • § 9058
    28 Mar 2025
    Found that the allegations of unlawful eviction, failure to conduct reassessments, failure to provide services as described in the admission agreement, and medication error were unfounded.
    28 Mar 2025
    Identified that the administrator completed 25 hours of live virtual training and 15 hours of online self-study in January–February 2024 on hazardous materials handling, emergency planning, staffing, and emergency communication; identified documentation of the first two quarters of staff training on how to respond to ingestion of cleaning products; and noted written acknowledgments that residents received copies of the stipulation and amended accusation, with leadership acknowledging stipulation conditions.
    • § 9058
    20 Dec 2024
    Found secure storage for cleaning products, proper labeling, and signs in both kitchens and dining areas that containers are for food only. Noted that staffing in the memory care unit met required ratios, the stipulation was posted, and the administrator was not present but acknowledged its conditions; no deficiencies identified.
    17 Sept 2024
    Found that a private duty aide provided personal care to a former client, while staff continued stand-by grooming twice daily. Found that the mouth sores allegation and the not-applying-ointment allegation could not be proven.
    18 Oct 2024
    Found that the allegation of no one answering the care home phone starting at 11:30 pm on 10/12/23 for about 2–3 hours occurred, with a cordless phone used by the nurse after 8 pm until 8 am and evidence of unanswered calls reported the next day. Schedule records showed an LVN and med tech on AM and PM shifts with 3–4 caregivers, and a night shift including an LVN and two caregivers; overnight staff were questioned, but it is unknown whether the overnight nurse was interviewed.
    • § 87468.1(a)(9)
    17 Sept 2024
    Found that the administrator completed 25 hours of live training and 15 hours of online study in early 2024 on hazardous materials handling, emergency planning, staffing, and communication with emergency services. Documented that the first two quarters of training for nine staff covered how to respond to ingestion of cleaning products or other hazardous materials, that residents acknowledged receipt of the stipulation and amended accusation, and that the administrator acknowledged the stipulation conditions including additional training and reporting; no deficiencies identified.
    17 Sept 2024
    Confirmed staff received required training on hazardous materials handling, emergency planning, and communication with emergency services. Staff also acknowledged receipt of important documents.
    19 Jun 2024
    Found no deficiencies and substantial compliance; the community included 135 living units on three floors, with a ground-floor memory care unit, and maintained safety, supplies, and hygiene measures, while several administrative forms and proof of liability insurance were requested by 7/3/24.
    19 Jun 2024
    Found signage in the main and lower-ground kitchen and dining areas that containers are for food and beverages only, and that the stipulation was posted, the policies manual kept in the copy room, written resident acknowledgments maintained, hazard communication forms signed by 10 staff, and Mr. Brooks acknowledged the stipulation conditions; no deficiencies cited.
    19 Jun 2024
    Observed compliance with stipulations regarding food and beverage container use, signage, hazardous materials policies, and staff acknowledgements during inspection.
    26 Jan 2024
    Reviewed stipulation agreements for two sites and their implementation status during a collaborative virtual meeting, with questions and clarifications addressed.
    26 Jan 2024
    Reviewed allegations of non-compliance and discussed stipulations during virtual meeting with facility representatives.
    05 Dec 2023
    Determined that the October 18 incident alleging a fall after an interaction initiated by one client with another had no reasonable basis; staff intervened, the second client's needs were assessed with a Resident Functional Needs Assessment and Service Plan completed and reviewed with the responsible party, and the incident was reported to the licensing agency.
    05 Dec 2023
    Determined that allegations of an incident on 10/18/23 were unfounded; video footage showed client #1 fell after an interaction with client #2, with staff intervening promptly, and all necessary assessments were completed.
    04 Dec 2023
    Found compliance with the stipulation, including secure storage of cleaning products, proper labeling, and signage about container use; staffing in memory care consisted of four caregivers for 21 residents, with Mr. Brooks acknowledging the conditions, and no deficiency noted.
    04 Dec 2023
    Investigated the allegation of abuse involving client #1. Met with a national operations specialist who provided additional details from surveillance video; additional information to be obtained; no deficiency cited.
    04 Dec 2023
    Observed secure storage of cleaning supplies and proper labeling of chemicals, along with appropriate staffing levels in the memory care unit. No deficiencies were identified.
    31 Oct 2023
    Found a deficiency in medication management when staff did not follow up on required information for a new resident, resulting in 24 hours with no medications, including insulin. A civil penalty was assessed.
    31 Oct 2023
    Identified deficiency in medication administration resulted in client not receiving necessary medications for 24 hours, leading to hospitalization.
    10 Oct 2023
    Found the meal timing delays and morning shower assistance allegations unfounded. Resulted in a medical emergency after admission due to missed medications; two staff were terminated.
    10 Oct 2023
    Investigated findings showed no evidence that staff neglected hygiene, diapering, or hydration, or ignored a request to wash hands. Determined that allegations of physical abuse and unwarranted charges had no reasonable basis; bruising observed earlier was explained by medications and movement, and a disputed charge about excessive toilet flushing was reversed.
    10 Oct 2023
    Reviewed facility records and conducted interviews with clients and staff to investigate allegations of inadequate care and abuse, ultimately finding that the allegations were unsubstantiated or lacking sufficient evidence.
    20 Sept 2023
    Investigated allegations that a resident left another resident's room overnight; a review of records and staff interviews found insufficient evidence to prove the allegation, with hourly checks documented and no distress observed.
    20 Sept 2023
    Reviewed records and interviewed staff to investigate an allegation regarding two clients in the memory care unit, finding it to be unsubstantiated due to lack of evidence.
    • § 87465(a)(4)
    • § 87466
    06 Sept 2023
    Found that the transportation-related allegation was unsubstantiated. The resident used the service about three times weekly for medical appointments, with pickups 30 minutes prior and destinations about five minutes away; the driver noted no missed appointments and only occasional 5–7 minute lateness due to tight scheduling.
    06 Sept 2023
    Reviewed client records, transportation schedules, and interviews with staff and clients, finding no evidence to support the allegation of untimely transportation for medical appointments.
    31 Aug 2023
    Investigated an allegation of inadequate daily living assistance, found the assessment underestimated needs for toileting and dressing and records did not fully reflect the actual care provided. Identified gaps in documentation of skin care and in communication about medications during relocation due to COVID.
    31 Aug 2023
    Determined that the allegation of only one staff member on duty overnight could not be proven or disproven after reviewing staffing calendars, time cards, surveillance video, and interviews.
    31 Aug 2023
    Confirmed inadequate assistance with toileting and dressing, but unsubstantiated claims regarding skin issues and medication management.
    15 Aug 2023
    Identified the allegation that wound status updates were not promptly communicated to the family, even though hospice should report condition updates. Found that nursing assessments were not monitored in a timely manner, which could have delayed wound treatment.
    • § 87466
    15 Aug 2023
    Determined that allegation of inadequate monitoring of wound care by staff, resulting in a delay in treatment, was substantiated, while the allegation of responsibility for reporting condition updates to the family by the hospice agency was unsubstantiated.
    14 Apr 2023
    Found that dishwashing detergent was improperly stored and transferred to residents, leading to ingestion. This caused two deaths and a third resident to be hospitalized with serious injuries; civil penalties totaling $39,500 were assessed.
    14 Apr 2023
    Confirmed violation of residents' personal rights resulting in serious bodily injuries and deaths, leading to a substantial civil penalty.
    21 Mar 2023
    Confirmed that department accusations for license revocation, administrator de-certification, and four staff exclusions were received and acknowledged; written notices were provided to residents, their responsible parties, and the local Ombudsman program, and an undated posting referencing the license action was observed. Reviewed applicable health and safety provisions with staff; no deficiencies found.
    21 Mar 2023
    Confirmed accusations of license revocation, administrator de-certification, and staff exclusions were acknowledged during the visit. Health and Safety Code 1569.38 was reviewed with the appropriate personnel. No deficiencies were found.
    03 Feb 2023
    Identified an allegation that immediate exclusion orders were issued for four residents, and documentation was amended to reflect this. The matter was reviewed with the director.
    03 Feb 2023
    Confirmed immediate exclusion orders were issued for multiple individuals.
    02 Feb 2023
    Identified Neglect/Lack of Supervision after three residents ingested dishwashing detergent, causing two deaths and serious injuries to the remaining resident. Found no clear procedures for pouring detergent from a five-gallon bucket into a one-gallon dispenser, and that caregivers assigned to kitchen duties did not receive chemical-handling training.
    • § 87555(b)(25)
    • § 87468.1(a)(2)
    • § 87309(a)(1)
    • § 87411(a)
    • § 87405(h)(1)
    02 Feb 2023
    Confirmed neglect and lack of supervision led to serious injury and death of residents due to ingestion of chemicals.
    • § 87464(d)
    26 Jan 2023
    Found no evidence to support the allegations that staff failed to observe or report changes in a resident's condition, failed to obtain medical intervention, or spoke disrespectfully to clients or handled them roughly.
    26 Jan 2023
    Investigated allegations of staff failing to observe or report changes in a resident's condition, obtain medical intervention, handling residents roughly, and speaking disrespectfully to them; found insufficient evidence to confirm any violations occurred.
    14 Dec 2022
    Identified an allegation that California Code of Regulations, Title 22 compliance was deficient during the complaint investigation.
    • § 9182
    23 Jan 2023
    Found that the LPA met with leadership, inspected door locks in the Life Guidance unit, and discussed residents’ access to personal toiletries unless their MD has written otherwise. Found that each shared suite has a lockable bathroom cabinet, and no deficiencies were identified.
    23 Jan 2023
    Inspected locking mechanism of doors in Life Guidance unit and addressed access to personal toiletries for clients during the visit.
    14 Dec 2022
    Found COVID infection-control measures in place at the site, including current temperature logs, PPE supply, and vaccination of staff and residents, with fire safety equipment and water temperatures within safe ranges. Identified one staff member without a completed fingerprint clearance, and a civil penalty was assessed.
    • § 87355(e)(1)
    14 Dec 2022
    Conducted an annual inspection focused on COVID infection control, observed compliance with regulations, and issued a citation for a violation.
    01 Dec 2022
    Reviewed reports dated 11/30/22 after technical difficulties and delivered them to the administrator today. An order of immediate exclusion was issued for a staff member related to the 11/15/22 incident, and no deficiencies were cited.
    30 Nov 2022
    Identified an allegation of harm to a client related to the 11/22/22 incident, reviewed staff and client files, and participated in a client interview with law enforcement. Found a deficiency tied to the 10/27/22 incident.
    30 Nov 2022
    Investigated a complaint alleging care-related injuries from a fall that led to death; found that documentation gaps and conflicting records prevented proving or disproving the allegation.
    30 Nov 2022
    Found the allegation unfounded after interviews with staff, a meeting with the administrator, and reviewing the staff file. Investigation began on 10/3/22 and included a follow-up on 10/24/22.
    30 Nov 2022
    Investigated an allegation that the May and June 2021 monthly assignment reports for a former resident were missing. Found that staff performed grooming, dressing, status checks, and continence support as indicated in the needs assessment, but the May and June 2021 reports were not available for review, and there was not enough evidence to determine whether the allegation occurred.
    01 Dec 2022
    Confirmed no deficiencies found during the inspection. One staff member received an Order of Immediate Exclusion.
    30 Nov 2022
    Investigated the complaint regarding a resident experiencing a fall and resulting injuries; determined that the evidence was insufficient to prove or disprove the alleged violation.
    24 Oct 2022
    Found that staff did not provide adequate bathing assistance per the care plan, completing only 11 of 16 planned showers for the client over eight weeks. Found that bruising seen on 6/3/21 was not documented earlier, while later notes described minor bumps and scratches from unsteadiness, and that records for laundry and room cleaning were inconsistent, with some items missing or damaged and compensation noted.
    • § 87464(f)(4)
    24 Oct 2022
    Confirmed inadequate assistance with showers and unsubstantiated claims of bruises and cleanliness issues. There were difficulties in adjusting to the environment.
    15 Sept 2022
    Determined that the allegations could not be proven or disproven due to insufficient evidence. Records showed new wounds treated by clinicians and a diet change after a swallow evaluation, with notes about weight loss mentioned but lacking documentation and no notes about staff meals.
    15 Sept 2022
    Found that PPE and donning/doffing instructions were not maintained in isolation carts outside rooms housing residents with COVID. Observed a posted notice requiring full PPE beyond that point, while some folding trays outside the rooms contained only a gown wrapped in plastic and two rooms had covered waste containers in the hall.
    • § 87468.1(a)(2)
    15 Sept 2022
    Confirmed lack of proper PPE maintenance in isolation rooms for residents with COVID.
    • § 1569.17(b)
    31 Aug 2022
    Found no citations issued during the visit, observed two kitchens on the first floor (one in LG and one in AL), rooms kept locked at all times, with 72 residents in AL and 27 in LG.
    31 Aug 2022
    Confirmed no violations found during the inspection.
    29 Jul 2022
    Reviewed the client file and related documents; internal investigation conducted; binder at the front desk listed residents unable to leave unassisted and updated as needed.
    29 Jul 2022
    Reviewed incident of client elopement, retraining provided to receptionist, and list of residents unable to leave unassisted updated as necessary.
    19 Aug 2021
    Investigated elopement incident involving a memory care resident; reviewed the resident's file and the room from which he exited, and reviewed procedures to identify who was on duty and who was responsible for responding to the alarm. Found 32 residents in memory care and 5 caregivers present today.
    19 Aug 2021
    Identified lack of COVID reminder signs to wear face coverings and maintain social distance indoors. Discussed with the maintenance director on 7/9/21 during annual inspection, and noted the entry sign is not adequate as a reminder; strongly advised posting individual reminder signs.
    19 Aug 2021
    Identified elopement incident from memory care unit, leading to review of procedures and staff responsibilities.
    09 Jul 2021
    Identified a three-floor complex with 135 living units, including a ground-floor memory care area with four exits and a prep kitchen, plus a large dining room, roof terrace, and common spaces for independent and assisted living residents. A deficiency in regulatory compliance was noted.
    09 Jul 2021
    Identified deficiencies in safety and operational procedures were observed during the inspection of the facility.
    29 Mar 2021
    Investigated allegations of insufficient staff, unqualified staff, improper post-fall assessment, and lack of dignity toward residents. Found enough staff on duty with adequate training; information about the post-fall assessment was insufficient to determine actions; and interviews indicated residents were treated with dignity.
    29 Mar 2021
    Investigated complaints regarding insufficient staffing, unqualified staff, improper assessment after a fall, and disrespect towards residents; none found to be supported with sufficient evidence.
    23 Mar 2021
    Identified that staff did not seek higher level of care or 1:1 support for a resident's wounds, despite nurse notifications, allowing the wounds to progress to Stage 4 and cause serious injury; an immediate civil penalty was assessed.
    • § 87411(a)
    23 Mar 2021
    Found that a resident developed a stage 3 pressure wound and the licensee failed to request an exception to retain the resident or provide a higher level of care, despite a nurse reporting the worsening condition. Found that the administrator did not meet required qualifications and duties during 04/18/20 through 04/24/20.
    23 Mar 2021
    Confirmed failure to provide proper care for a resident with a serious medical condition.
    22 Mar 2021
    Found the admission agreement for the resident was tentative and the medical records showed a higher level of care was required that could not be met, with no payment made for admission. There was not enough evidence to prove the allegation.
    22 Mar 2021
    Found that the facility did not comply with the admission agreement due to the resident needing a higher level of care that the facility could not provide.
    • § 87355(c)
    15 Mar 2021
    Found insufficient evidence to prove the allegations that staff did not meet the resident's medical needs and that staff did not transport the resident to appointments; records showed the resident attended medical appointments and transportation occurred.
    15 Mar 2021
    Investigated allegations of staff not meeting medical needs and not transporting a resident to appointments; determined insufficient evidence to substantiate claims.
    • § 87405(d)(1)
    20 Oct 2020
    Identified an elopement incident in which a resident attempted to exit through a Memory Care window but was intercepted by staff before leaving, with a window alarm alert; no injuries occurred.
    20 Oct 2020
    Identified incident of elopement from Memory Care, but no injuries reported. Corrective actions taken, including 1:1 care and staff training.
    05 Mar 2020
    Completed renovations included opening of the Wellness center, activities area/engaged life center, main living room, and Bistro. The remaining 15 rooms and pending details were scheduled to be finished by the end of March.

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