415600980-11-18-2022-14-AS-KHOS-CQCM9V-20230328092522

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600980
Report Date: 11/18/2022
Date Signed: 11/18/2022 12:03:25 PM

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
09/30/2022 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220930114947

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: 157	DATE:	11/18/2022
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Freddie Fullon		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility is providing inadequate food services to residents in care.

INVESTIGATION FINDINGS:

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On this day Licensing Program Analyst (LPA) conducted an unannounced complaint investigation visit to deliver findings regarding the allegation receivded. LPA met with executive director/administrator Freddie Fullon and explained the purpose of today's visit.

During the course of the investigation LPA interviewed staff, outside agency, and reviewed the facility's policy regarding food services and feeding in the memory care unit that is outlined in the admission agreement. It is discovered that food is provided regularly to all residents but one on one feeding is not provided by staff. According to an interview conducted with resident services director (RSD)/nurse Angel Bustos, hand to mouth feeding is not provided in memory care. Staff are trained to observe and prompt residents to self feed. Sometimes staff will assist a resident by placing the fork or spoon in residents hand and helping the resident raise the spoon to the resident's mouth to remind the resident to eat.

Continued on Page 2...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022

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-20220930114947

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: 11/18/2022

NARRATIVE

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Page 2 - LIC9099C

When speaking to both the RSD/nurse and the administrator, if a resident cannot self feed at any point then the responsible party for that resident has to acquire outside help to provide that one on one feeding to that specific resident. Upon review of the admission agreement, and specific to memory care, it is outlined that one on one feeding is not provided by the facility. The facility is providing food but is not providing one on one, or hand to mouth, feeding of residents in memory care. Due to these discoveries the allegation is unsubstantiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022

LIC9099 (FAS) - (06/04)

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