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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600980
Report Date: 03/29/2022
Date Signed: 03/29/2022 03:24:20 PM


Document Has Been Signed on 03/29/2022 03:24 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:ATRIA AT FOSTER SQUAREFACILITY NUMBER:
415600980
ADMINISTRATOR:FREDDIE FULLONFACILITY TYPE:
740
ADDRESS:707 THAYER LNTELEPHONE:
(650) 532-2460
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY:216CENSUS: 144DATE:
03/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:36 PM
MET WITH:Administrator, Freddie FullonTIME COMPLETED:
03:30 PM
NARRATIVE
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On 3/29/2022, Licensing Program Analysts (LPA) Murial Han conducted an unannounced case management visit to follow-up on a complaint investigation. LPA Han met and explained the purpose of the visit with the assistant administrator, Siobhan Surracao while the administrator, Freddie Fullon was busy at the moment then the administrator took over and assisted with the rest of the visit.

The Department investigated allegations under complaint # 14-AS-20210913142555, regarding a resident sustaining a fracture while in care; facility refusing to accept resident back to the facility; and facility failing to report/provide information to the injured resident’s family.

During the course of investigating the allegation of the resident sustaining a fracture while in care, there was a caregiver (identified as S1 in complaint 14-AS-20210913142555) who was with the resident #1 (R1) prior to the resident being removed by emergency personnel. Upon arrival to the hospital, R1 was found to be suffering of a right shoulder fracture, spleen laceration, and left buttocks bruising consistent with traumatic injuries. S1 has failed to cooperate with the Department investigation.

During the course of investigating the allegation, the department asked the administrator to provide camera footage to the Department to determine who was with the resident when the paramedics arrived, and who could had been present before removal of the resident by the paramedics. The administrator failed to provide the actual footage despite numerous requests to do so.

A resident went to the hospital early in the morning of 8/31/2021. After a stay at the hospital for couple of weeks, the resident was discharged back to the facility on 9/9/2021. According to the administrator and the resident service director, R1 was readmitted with health conditions and needs that were not previously required and the facility was not capable of caring for R1 under these new health conditions. Therefore, the administrator gave R1, as only options, to stay as long as R1’s responsible party hire a personal skill professional to care for the resident, or to have R1 transferred back via ambulance to the hospital.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


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 AT FOSTER SQUARE
FACILITY NUMBER: 415600980
VISIT DATE: 03/29/2022
NARRATIVE
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The administrator illegally evicted a resident when failing to follow Section 87224. The licensee failed to reappraise a resident before admitting him/her back from a hospital stay; then, upon readmission, the resident was cursorily deemed beyond the level of care (without a formal appraisal) and sent back to the hospital. The facility has been cited on a LIC 9099D under complaint number 14-AS-20210913142555.

A resident had a change of condition during the night of 8/30/2021 and early hours of 8/31/2021. The facility had failed to update the resident’s emergency card, so the notification of the resident’s condition went to a contact person out of State, and who unable to respond to the resident’s situation and in so doing violating Section 87468.1 (a) (8) Personal Rights of Residents in All Facilities. The facility has been cited on a LIC 9099D under complaint number 14-AS-20210913142555.

Given the above information the facility is cited under:

· 87755 (b) Inspection Authority of the Licensing Agency - The licensee shall ensure that provisions are made for private interviews with any resident or any staff member; and for the examination of all records relating to the operation of the facility.
· 87755 (c) Inspection Authority of the Licensing Agency - The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed, if necessary, for copying.
· 87405 (d) (2) Administrator - Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to the applicable laws, rules and regulations.
· 87411 (a) Personnel Requirements – General - Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

Based on interviews and record reviews during the investigation, deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the administrator. A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/29/2022 03:24 PM - It Cannot Be Edited

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 AT FOSTER SQUARE
FACILITY NUMBER: 415600980

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2022
Section Cited

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87755 Inspection Authority of the Licensing Agency (b)The licensee shall ensure that provisions are made for private interviews with any resident or any staff member; and for the examination of all records relating to the operation of the facility. This requirement is not met as evidence by:
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During the couse of investigating the allegation, there was a caregiver identifed as S1 who was present with R1 right before R1 was transferred to the hospital but S1 was not coorporative with providing any inforamtion to assist with the investigation despite many attempts made by LPA including requesting the administrator to have S1 contact LPA which posed a potential health and safety risks to resident in care.
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The administrator and/or the designee shall educate staff on this regulation and provide a copy of the education lesson plan and a copy of the sign-in sheet to CCL by the due date of 4/12/2022.
Type B
04/12/2022
Section Cited

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87755 Inspection Authority of the Licensing Agency(c)The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. This requirment is not met as evidency by:
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The administrator has failed to provide the camera footage to the Department as requested which posed a potential health and safety risks to resident in care.
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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 MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 03/29/2022 03:24 PM - It Cannot Be Edited

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 AT FOSTER SQUARE
FACILITY NUMBER: 415600980

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2022
Section Cited

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87405 Administrator - Qualifications and Duties(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)..(2)Knowledge of and ability to conform to the applicable laws, rules and regulations.
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This requirement is not met as evidenced by the administrator failed to provide the camera footage as requested by the Department and the administrator failed to ensure staff is corporative with investigation process which posed potential health and safety risks to resident in care.
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Type B
04/12/2022
Section Cited

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87411 Personnel Requirements - General(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required.... the requirement is not met as evidence by:
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The facility failed to conduct a reappraisal prior to readmitting R1 from the hospital with health conditions and needs that were not previously required. Therefore, the facility failed to enure sufficient support staff were equipped to provide care to R1 which posed a potential health and safety risks to resident in care.
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The administrator shall educate facility staff and submit a copy of the lesson plan and a copy of the sign-in record to CCL by the plan of correction due to 4/12/2022.
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 MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4