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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 03:05:22 PM


Document Has Been Signed on 03/29/2022 03:05 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:POCUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Freddie FullonTIME COMPLETED:
03:20 PM
NARRATIVE
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On 3/29/2022, Licensing Program Analysts (LPA) Murial Han conducted an unannounced plan of correction (POC) visit to verify and to confirm that the facility is in compliance with the citation that was issued on 3/8/2022. 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.

On 3/8/2022, the facility received a citation for not providing medical record to the responsible party as requested and the plan of correction was due on 3/22/2022 that required the facility to provide the following documents to the responsible party and a copy to Community Care Licensing (CCL).

- A list of Medication that was administered from 8/30/21- 8/31/21
- Documentation related to the hospital transfer on 8/31/21
- The assessment/service plan that was conducted by the resident service director and the responsible party including the times that R1 would be checked on by staff and the documentation of who and when R1 was checked on.
- A list of the times that R1 was checked on as shown on the camera footage from 8/30/21 7PM- 8/31/21.
- R1's diagnosis and facility documentation related to the ambulance transportation on 9/9/2021.

As of 3/29/2022, the facility has not submitted any proof to CCL that the plan of correction was completed and the responsible party has not received any documents from the facility..Therefore, CCL is reissuing the citation and assessing for civil penalty of $100 per day between 3/23/2022- 3/28/2022 in the amount of $600. Civil penalty will continue at $100 per day starting from 3/29/2022 until the plan of correction is completed.

Based on information above, deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809D. Failure to correct the deficiencies will result in additional civil penalties.

This report is discussed and reviewed 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
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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Document Has Been Signed on 03/29/2022 03:05 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
04/05/2022
Section Cited

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PERSONAL RIGHTS OF RESIDENTS....(a)Residents in all residential care facilities....(9) To have communications to the licensee from their representatives answered promptly and appropriately.
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This requirement was not met as evidenced by: the facility failed to provide R1's medical records as requested by the responsible party promptly and appropriately as requested which posed potential health and safety risks to resident in care.
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The administrator will review this regulation and submit a statement of acknowledgment after the review by the plan of correction due date 4/5/2022.

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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)
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