415600980-9-12-2024-14-AS-KHOS-D9DMPJ-20240923094713

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600980
Report Date: 09/12/2024
Date Signed: 09/12/2024 01:07:35 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
06/27/2024 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240627121223

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: 169	DATE:	09/12/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Administrator, Freddie Fullon		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Staff do not ensure that resident's records contain correct information

INVESTIGATION FINDINGS:

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On September 12, 2024 Licensing Program Analyst (LPA), Murial Han conducted an unannounced visit to deliver the complaint investigation findings. LPA met with the administrator and explained the purpose of today's visit.

Regarding to the allegation of- staff do not ensure that resident's records contain correct information, the reporting party stated that resident #1(R1) date of birth was incorrect on the facesheet.

Based on R1's facesheet, LPA observed the date of birth on the facesheet is different from the other documents such as the Physician's Order, and the Medication Administrator Records and the responsible party verified that the date of birth is correct on the other documents but not the facesheet.

After the investigation, this allegation is deemed to be substantiated.

Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed and reviewed with the Assistant Administrator, Kari Jane.

A copy of this report and the Appeal Rights is provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
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.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 14-AS-20240627121223

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 SQUARE	FACILITY NUMBER: 415600980
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/18/2024 Section Cited CCR 87506(a)	1 2 3 4 5 6 7	87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility....	1 2 3 4 5 6 7	The administrator/Licensee will develop a plan to ensure this does not happen again and will provide in-service to those who are involved with this process. The administrator will provide a copy of the plan and training
	8 9 10 11 12 13 14	This requirment is not met as evidenced by base on observation, interveiw and records review, R1's date of birth is incorrect on R1's facesheet which poses a potential health risk to residents in care.	8 9 10 11 12 13 14	records to CCL by 9/18/2024.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
06/27/2024 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240627121223

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: 169	DATE:	09/12/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Administrator, Freddie Fullon		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Staff are charging resident for services not rendered
Staff did not report an incident to appropriate parties

INVESTIGATION FINDINGS:

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On September 12, 2024 Licensing Program Analyst (LPA), Murial Han conducted an unannounced visit to deliver the complaint investigation findings. LPA met with the administrator and explained the purpose of today's visit.

Regarding to the allegation of- staff are charging resident for services not rendered, the reporting party stated that the responsible party provided a 30-day discharge notice for R1 and when the notice was provided, the director acknowledged it but never mentioned anything about a 60-day discharge notification and the facility continued to charge R1 after he/she was discharged after the 30-day discharge notice.

According to R1's responsible party, the allegation has been resolved as the facility has waived the fee that was incurred after R1's discharge.

After the investigation, this allegation is deemed to be unsubstantiated.

Regarding to the allegation of staff did not report an incident to appropriate parties, the reporting party stated that R1 was transferred to the hospital in April 2024 and the facility did not notify the responsible party and the emergency contact.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
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.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 14-AS-20240627121223

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 SQUARE	FACILITY NUMBER: 415600980
	VISIT DATE: 09/12/2024

NARRATIVE

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The administrator denied the allegation and provided documentation indicating that R1's responsible party was notified on the date of R1's hospital transfer.

LPA interviewed another resident's responsible party who stated that he / she was notified by the facility when his/her loved one had a change of condition.

Based on observation, interviews and records review, this allegations is deemed to be unsubstantiated.

Although the above allegations 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.

This report is review with the assistant administrator and a copy is provided

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
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

LIC9099 (FAS) - (06/04)

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