415600980-2-17-2023-14-AS-KHOS-CPNPGC-20230306101805

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600980
Report Date: 02/17/2023
Date Signed: 02/17/2023 10:23:42 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/16/2022 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20221116095411

FACILITY NAME:	ATRIA AT FOSTER SQUARE		FACILITY NUMBER:	415600980
ADMINISTRATOR:	FREDDIE FULLON		FACILITY TYPE:	740
ADDRESS:	707 THAYER LN		TELEPHONE:	(650) 532-2460
CITY:	FOSTER CITY	STATE: CA	ZIP CODE:	94404
CAPACITY:	216	CENSUS: 148	DATE:	02/17/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Executive Director, Freddie Fullon		TIME COMPLETED:	10:32 AM

ALLEGATION(S):

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-Facility staff abandoned resident
-Facility staff did not meet needs of resident while COVID positive
-Facility staff did not follow admission agreement
-Facility staff photographed resident without consent
-Facility staff shared resident's confidential information to a non-authorized party

INVESTIGATION FINDINGS:

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On February 17, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Executive Director, Freddie Fullon and explained the purpose of the visit.

Regarding the allegation that facility staff abandoned resident and facility staff did not meet needs of resident while COVID positive, according to the reporting party, Resident #1 (R1) tested positive for COVID-19 on 10/19/22 and the facility called R1’s responsible party to have R1 picked up due to being COVID positive. In addition, according to the reporting party, the facility did not reach out to the responsible party to see when R1 was going to return back to the community after isolation period.

During the investigation, LPA interviewed staff and reviewed R1’s file. According to the administrator, R1 has a wandering behavior and the facility did not want to risk any other residents from testing positive. According to interviewed staff, during the time R1 was COVID positive, staff tried to redirect R1, however it was difficult because R1 is a wanderer and did not follow COVID protocols. The administrator indicated that he contacted R1's responsible party and gave him/her an option to hire a private caregiver or to take R1 and have him/her isolate at home. On 10/20/22, R1’s responsible party picked R1 up from the facility to isolate at home. Based on documentation reviewed, R1’s responsible party contacted the facility on 10/24/22, requesting the facility to test R1 to see if he/she tests negative due to R1’s responsible party having difficulties taking care of R1 at home. Furthermore, when R1 was brought to the facility on 10/25/22 to get tested, R1 still tested positive and had to isolate for the full 10 days. According to the administrator, the facility contacted R1’s responsible party several times to ask when R1 would be returning back to the community however did not receive a call back or response from the responsible party. (CONT. TO 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20221116095411

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 SQUARE	FACILITY NUMBER: 415600980
	VISIT DATE: 02/17/2023

NARRATIVE

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Regarding the allegation that facility staff did not follow admission agreement, according to the reporting party, the facility required R1's responsible party to pay for the month of November after facility was notified on 10/28/22 that R1 will not be returning to the facility. During the investigation, LPA reviewed the facility's admission agreement. According to the admission agreement, the responsible party can terminate the agreement at any time by providing the facility a written notice of termination at least 30 days prior to the date of the termination stated in the notice. In addition, the admission agreement indicates that the responsible party will be responsible of all fees and expenses incurred during the 30-day notice period. Based on documentation reviewed, on 10/28/22, R1's responsible party provided the facility with a notice indicating that R1 will not be returning back to the community and that all of R1's belongings will be picked up by 10/31/22. Furthermore, on 10/31/22, the administrator emailed the responsible party back indicating a 30-day notice would have to take place from 10/28/2022, and called to notify the responsible party that R1 may return back to the community.

Regarding the allegation that facility staff photographed resident without consent and facility staff shares resident’s confidential information to a non-authorized party, according to the reporting party, a staff member took photos on their phone of R1’s accidents and shared the photos with an individual who came to visit R1.

During the investigation, LPA reviewed R1’s files, reviewed staff roster and staff schedules, and interviewed the administrator and the witness. Based on the file reviewed, LPA observed a copy of the facility's photo/video consent form signed by R1's responsible party. Based on the interview conducted with the witness, it was indicated that a staff showed him/her pictures of R1’s incontinent accidents. LPA reviewed the staff roster, and the staff schedules for the dates that was provided by the witness, however there was no staff member that fit the name or description as identified by the witness. According to the administrator, the facility staff takes photos or resident’s accidents to report to the Administrator, resident’s responsible parties or the physician.

Therefore, based on the documents collected, information reviewed, and interviews conducted, the allegations above are UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Report is reviewed with Executive Director, Freddie Fullon and a copy is provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC9099 (FAS) - (06/04)

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