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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600980
Report Date: 09/28/2022
Date Signed: 09/28/2022 01:05:33 PM


Document Has Been Signed on 09/28/2022 01:05 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
SF COASTAL AC/SC, 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: 160DATE:
09/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Freddie FullonTIME COMPLETED:
01:15 PM
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On September 28, 2022, Licensing Program Analyst (LPA) Komal Charitra, conducted an unannounced case management visit to follow up on an incident that was reported to CCLD on June 23, 2022. LPA met with Administrator, Freddie Fullon and explained the purpose of the visit.

The Licensee reported on 6/23/22, resident #1 (R1) AWOL (Absent Without Official Leave). During the visit, LPA reviewed R1's file and interviewed staff. According to the files reviewed, R1 has a diagnosis of dementia and is not able to leave the facility unassisted. Furthermore, LPA reviewed R1's needs and service plan and upon admission R1 was on status checks and escorting for transition to the community. On 6/28/22, R1's needs and service plan addressed R1's confusion, impaired judgement, and risk of elopement and the facility's intervention upon admission was ensuring a private caregiver was assigned to R1 for about 2 months and ensured there was frequent communication with R1's Geriatric specialist.

According to the Administrator, R1 was seen in the dining room hall around 8:15am and at 9:30am, it was reported by Med-Tech that R1 was unable to be located. Staff searched the entire community and the premises. In addition, it was indicated that community directors searched by car within 10 miles radius and found R1, about 3 miles away from the facility. According to the Administrator, after this incident occurred, all required parties were notified and a private caregiver was assigned to R1 till R1 moved into a secure environment.

Based on interviews and file reviewed during the visit, the facility did attempt to ensure basic services were being met for R1. No citations will be issued at this time.

Report is reviewed with Administrator, Freddie Fullon and a copy is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022
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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