<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600980
Report Date: 12/26/2023
Date Signed: 12/26/2023 05:26:48 PM

Document Has Been Signed on 12/26/2023 05:26 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: 146DATE:
12/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Freddie FullonTIME COMPLETED:
02:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On December 26, 2023 Licensing Program Analyst (LPA) Murial Han conduct an annual inspection. LPA met with administrator, Freddie Fullon and explained the purpose of today's visit.

Administrator provided a tour of the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a 6 floor facility; 1st floor being the entrance to the lobby, 2nd floor for Life Guidance (LG) residents and common areas, 3rd-6th for Assisted Living (AL) and Independent Living (IL). All floors have elevators.

Medications are locked in the medication rooms and inaccessible to residents in care. A comfortable temperature is maintained between 71- 74 degrees F and lighting is sufficient for comfort.

Chemicals, toxins, and sharps objects were locked and inaccessible to residents.

2 days of perishables and 7 days of nonperishable foods were observed for the residents.

Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher was last serviced on 8/3/2023. Fire drill records observed to be sufficient. Egress delay door in the Life Guidance unit was tested to be adequate.

Hot water temperature through-out the facility is measured at 106- 111 degrees F.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/26/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA reviewed 5 resident records and all of them contained admission agreement, medical assessment- LIC 602 (Physician Order), Appraisal Needs and Service Plan, admission agreement, Resident Identification information, Pre-appraisal assessment, etc.
LPA reviewed 5 staff files and all of them contained personnel records, health screening, COVID-19 vaccination information, Job Description, Abuse Statement, First Aide/CPR, Criminal Record Statement, fingerprint cleared and associated to the facility.

No deficiency is cited.

This report is reviewed and discussed with the administrator; a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2