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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600980
Report Date: 09/12/2024
Date Signed: 09/12/2024 01:06:40 PM

Document Has Been Signed on 09/12/2024 01:06 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ATRIA AT FOSTER SQUAREFACILITY NUMBER:
415600980
ADMINISTRATOR/
DIRECTOR:		FREDDIE FULLONFACILITY TYPE:
740
ADDRESS:707 THAYER LNTELEPHONE:
(650) 532-2460
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 216CENSUS: 169DATE:
09/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:06 PM
MET WITH:Administrator, Freddie FullonTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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On September 12, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management visit to follow up on an incident that was reported by the facility. LPA met administrator, Freddie Fullon and explained the purpose of today's visit.

On August 1, 2024, the facility reported that resident #1 (R1) was transferred to the hospital due to a change of condition and while at the hospital, R1 verbalized to the hospital staff that he/she was afraid of a caregiver as the caregiver was being unprofessional while caring for R1.

Subsequently, the hospital reported to the facility and the facility conducted an investigation, and reported it to the Local Police Department and the Ombudsman.

R1 has returned to the facility and the facility has implemented new interventions to ensure R1 feels safe at the facility.

During today's visit, LPA met with R1 who stated that everything has improved since meeting with the Administrator and the Resident Service Director. R1 also stated that all the caregivers are very professional and nice.

No deficiency is cited today.

This report is reviewed and discussed with the Assistant Administrator, Kari Jane and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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