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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600980
Report Date: 09/13/2023
Date Signed: 09/13/2023 01:48:47 PM


Document Has Been Signed on 09/13/2023 01:48 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: 143DATE:
09/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator, Freddie FullonTIME COMPLETED:
02:00 PM
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On September 13, 2023, Licensing Program Analyst (LPA), Murial Han conducted an announced case management visit to follow up on an incident that was reported by the facility. LPA met with administrator and explained the purpose of today's visit.

On September 7, 2023, facility reported to CCL that resident #1 (R1)'s responsible party reported to the facility that on September 1, 2023, R1 left the facility, went for a walked and returned. Facility staff reviewed the video footage and discovered that R1 exited the facility through the back elevator, and returned within 15 minutes.

During today's visit, LPA toured the route of how R1 exited the facility, interviewed R1 and the responsible party, administrator, resident service director and resident service coordinator.

Based on the incident report, it was indicated that R1 has diagnosis of dementia and is unable to leave the facility unassisted. However, based on R1's physician's report dated on May 10, 2023, R1 was not at risk for leaving the community unsupervised and this was verified in the presence of the administrator.

According to R1, he/she took the elevator down, got off in the garage, pressed the button to open the garage door, and left. R1 stated that he/she was not lost, not scared, walked around the facility and returned in a few minutes.

As part of R1's service plan, facility will continue to check on R1 every 2 hrs.

No deficiency cited today.

This report is reviewed and discussed with the administrator. A copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023
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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