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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600980
Report Date: 03/29/2022
Date Signed: 03/29/2022 02:57:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/13/2021 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210913142555
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
UNANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Administrator, Freddie FullonTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility refused to accept resident back to the facility
Staff are not returning authorized representative's call
INVESTIGATION FINDINGS:
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On 3/29/2022, Licensing Program Analysts (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20210913142555. 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.

Regarding to allegation of- the reporting party stated that the facility refused to accept resident back to the facility after R1's hospitalization.

A resident went to the hospital early in the morning of 8/31/2021. After a stay at the hospital for a 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 hires a personal skill professional to care for the resident, or to have R1 transferred back via ambulance to the hospital.

Section 87224 Eviction Procedures specifies that the licensee may evict a resident if, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. The information collected provides preponderance of evidence to show that the facility failed to evaluate R1 before admitting R1 back from the hospital. Once readmitted, the facility was required to perform a reappraisal and then to follow 30-day eviction procedures if it had been determined that the facility was unable to meet the resident’s level of care. By not following those rules, the licensee illegally evicted the resident.

Based on this information, the allegation is substantiated.

Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 14-AS-20210913142555
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 allegation that facility staff fails to communicate with resident’s authorized representative refers to the facility failing to report R1’s hospitalization to designated R1’s responsible party.

According to the administrator, R1 had a change of condition during the night of 8/30/2021 and early hours of 8/31/2021. Staff #1 (S1) on the night shift was not familiar with the local responsible party listed in the contact list, and instead called one of the emergency contacts who lives in Florida, and who was unable to readily attend to R1’s emergency. Since this incident, the administrator reported that the facility has revised R1's contact sheet and added R1's responsible party under emergency contact.

Section 87468.1 (a) (8) Personal Rights of Residents in All Facilities states that residents in all residential care facilities for the elderly shall have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. By failing to maintain an accurate record, the facility failed to notify the responsible party when R1 was transferred to the hospital. Therefore, based on the above information, interviews and record review, this allegation is substantiated

Based on interviews, observations and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, these allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed with Administrator, and Appeal Rights provided. A copy of 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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/13/2021 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210913142555

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: DATE:
03/29/2022
UNANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Administrator, Freddie FullonTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident sustained a fracture while in care
INVESTIGATION FINDINGS:
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On 3/29/2022, Licensing Program Analysts (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20210913142555. 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.

Regarding to allegation of- resident sustained a fracture while in care, the reporting party believes that the fracture was sustained at the facility but does not have any specific details as to how it happened.

The facility has a camera in the hallway which captured the staff who entered and exited resident #1 (R1)'s room. 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 provided a list of 5 staff who entered and exited R1’s room between 8/30/2021 at 7:56PM and 8/31/2021 at 6:11am. However, the licensee failed to provide the actual footage despite numerous requests to do so.

According to 3 out of 5 staff interviewed, there were no incidents that could have caused R1's fracture. Another staff (S1) is known to have been with the resident until the paramedics arrived. S1 has not cooperated with the Department and has not provided a statement or assisted with this investigation despite multiple attempts of phone calls and also requesting the administrator to relay messages.

Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 14-AS-20210913142555
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 sequence of events indicates that late on 8/30/2021, the resident had an anxiety attack. The facility called emergency services early on 8/31/2021. There was a caregiver (S1) with the resident when paramedics arrived. The resident was then transported to the hospital. EMS records did not note any incidents during transfer or at the hospital. However, once at the hospital it was discovered that the resident had a right shoulder fracture, spleen laceration, and left buttocks bruising consistent with traumatic injuries. The injuries could had been caused by a fall, or cardio embolic source, but medical personnel were unable to rule any possibility out.

The Department has been unable to interview the caregiver (S1) who was with the resident until the EMS arrived, and who could provide information on about what could had happened. The Administrator has also proven uncooperative.

Base on record review and interviews during the course of investigation, this allegation is unsubstantiated.

Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with the facility's 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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20210913142555
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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)
Request Denied
Type A
04/01/2022
Section Cited
CCR
87224(a)(4)
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87224 Eviction Procedures(a) The licensee may evict a resident..Thirty (30) days written notice to the resident is required..(4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted..This requirement was not met as evidenced by:
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The administrator will review the regulation and submit a signed written statement of acknowledgment to CCL by the plan of correction due date 4/1/2022.
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On the day of R1's readmission to the facility from the hospital with health needs that were not previously identified. The administrator offered R1's responsible party to either hire a personal skill professional to care for the resident or to have R1 transfer back to the hospital. The facility failed to perform a reappraisal and issue a 30-day evict notice which posed immediate health and safety risks to resident in care.
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The administrator will educate facility on this regulation and provided a copy of the lesson plan and a copy of the facility staff sign-in record to CCL by the plan of correction due date 4/1/2022.
Request Denied
Type B
04/12/2022
Section Cited
CCR
87468.1(a)(8)
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87468.1Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities..shall have.(8) To have their representatives regularly informed by the licensee of activities related to care...This requirement was not met as evidence by:
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The administrator and/or the designee will review and verified all the resident's contact information to ensure accuracy and provide a statement to CCL after the verification of completion by the plan of correction due date 4/12/2022.
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When R1 was transferred to the hospital, the facility failed to contact the local responsible party listed in the contact list, and instead called one of the emergency contacts who lives in Florida, and who was unable to readily attend to R1’s emergency which posed potential health and safety risks to resident in care.
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The administrator and/or the designee will provide education to staff on the sequencing of calling resident's contacts based on the contact list and will provide a copy of the staff sign-in record to CCL by the due date 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
LIC9099 (FAS) - (06/04)
Page: 5 of 5