415600980-5-1-2024-14-AS-ACON-D59QSY-20240514122621

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600980
Report Date: 05/01/2024
Date Signed: 05/01/2024 10:33:45 AM

Substantiated

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
02/21/2024 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240221132757

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: 155	DATE:	05/01/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator, Freddie Fullon		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Staff do not allow resident direct access to personal grooming and hygiene items.
Licensee does not abide by the terms of resident’s admission agreement.

INVESTIGATION FINDINGS:

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On May 1, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the complaint findings. LPA met with administrator and explained the purpose of today's visit.

Regarding to the allegations of- staff do not allow resident direct access to personal grooming and hygiene items, and licensee does not abide by the terms of resident's admission agreement, the reporting party stated resident #1 (R1)'s grooming and personal toileting items are not accessible to R1 as they are locked up by facility staff and it is in violation of the Admission Contract under Statement of Residents' Personal Rights that indicated residents have the right to keep, have access to, and use their own personal possessions, including toilet supplies.

As part of the investigation, LPA interviewed facility directors, and facility staff.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

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 6

Control Number 14-AS-20240221132757

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: 05/01/2024

NARRATIVE

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The facility directors acknowledged that facility staff locked R1's grooming items such as the toothpaste, and toothbrush for safety reasons but those items did not required to be locked as they are not harmful to the residents and residents shall have access to them when needed.

According to facility staff, they locked R1's toiletries such as toothpaste and toothbrush for safety reasons and they were aware that items shall not be locked as they are not harmful to the residents.

After the investigation, this allegation is deemed to be substantiated. The facility's action was to ensure resident's safety, however, the toiletries were approved and deemed by the facility to be safe, therefore, it shall not be locked and residents shall have access to their own personal possessions, including but not limiting to their toilet articles.

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 administrator.

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

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 14-AS-20240221132757

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 05/07/2024 Section Cited CCR 87468.1(a)(12)	1 2 3 4 5 6 7	87468.1Personal Rights of Residents in All Facilities..(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:..12) To wear their own clothes; to keep and use their own personal possessions, including their toilet articles;...	1 2 3 4 5 6 7	The administrator/licensee will develop a plan to ensure residents have access to their own personal possessions at all time and will submit a copy of the plan to CCL by 5/7/2024. The plan shall include staff training.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by based on observation and interview, facility locked up R1's toothbrush and toothpaste which poses a potential health risk to resident in care.	8 9 10 11 12 13 14
	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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 6

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
02/21/2024 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240221132757

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:	DATE:	05/01/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator, Freddie Fullon		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Staff did not appropriately evaluate resident’s service needs.
Staff do not ensure resident is accorded privacy in personal accommodations.

INVESTIGATION FINDINGS:

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On May 1, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the complaint findings. LPA met with the administrator and explained the purpose of today's visit.

Regarding to allegation of staff did not appropriately evaluate resident's service needs- the reporting party stated that resident #1 (R1) had a change of condition in January 2024 which resulted in hospitalization and upon R1's return, R1's monthly rent was increased by $1700 because the facility added points to R1's grooming and R1 did not need assistance with grooming pertaining to tooth brushing.

As part of the investigation, LPA interviewed the administrator, resident service director, resident service supervisor, facility staff and reviewed documents.

LPA interviewed the administrator who denied the allegation and stated that R1's initial functional needs care profile was developed from the preplacement appraisal that was conducted by the resident service supervisor, the LIC 602 (physician's order), and facility staff observation. The administrator stated that the responsible party was not in agreement of the functional needs care plan as it triggered a higher monthly fee for R1 due to grooming, therefore, a meeting was held with R1's responsible party, other family members and facility's directors to discuss R1's functional needs plan.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 14-AS-20240221132757

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: 05/01/2024

NARRATIVE

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According to the resident service director and resident service supervisor, R1's functional needs care profiles were developed based on R1's LIC 602, their assessment and staff's observation while providing care to R1 and based on the observation details, R1 needed assistance/queueing with grooming such as tooth brushing even when the toiletries were available for R1, combing hair, etc. In addition, they stated that grooming is not only pertaining to brushing teeth, it also included combing hair, cleaning face, applying deodorant, etc.

Furthermore, the resident service director and the resident service supervisor reported that R1's responsible party did not agree with the functional needs care profile for R1 as grooming was triggered resulted in additional monthly fee. Therefore, the facility conducted a meeting with the responsible party and other family meeting to discuss the accuracy of the functional needs care profile. During the meeting, adjustments were made, however, they were not significant enough to reduce the monthly fee. In addition, they stated that the functional needs care profile for R1 was developed according to the feedback from the direct care staff and R1's LIC 602.

LPA interviewed 2 facility staff members and both of them reported that R1 needed queuing with brushing his/her teeth on a daily basis and sometimes needed assistance. They also reported that they assisted R1 with other grooming tasks such as combing hair, cleaning face, washing hands, etc.

Based on documents provided by the facility and the reporting party, R1 had a change in health condition in January and resulted in hospitalization. Prior to R1's return, on January 30, 2024, the resident service supervisor conducted a preplacement appraisal. Upon R1's return, on February 1, 2024, the facility developed R1's Functional Needs Care Profile based on R1's LIC 602. On February 7, 2024, R1's Functional Needs Care Profile was revised and a meeting was held with R1's responsible party, other family members and facility directors to discuss R1' Functional Needs Care Profile as R1's responsible party disagreed with some of the tasks that were triggered.

Based on the R1's care log that was completed by the direct care staff members, it revealed that R1 needed assistance with grooming such as dressing, brushing teeth, combing hair, etc.

Based on interviews, observation and record review during the investigation, this allegation is deemed to be unsubstantiated as the facility conducted necessary appropriate steps to evaluate R1 prior to admission and revised the Functional Needs Care Profile for R1 accordingly.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 14-AS-20240221132757

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: 05/01/2024

NARRATIVE

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Regarding to allegation of- staff do not ensure resident is accorded privacy in personal accommodations, the reporting party stated that when R1 returned from visiting with family, there was another resident found laying R1's bed.

The administrator acknowledged that another resident was found on R1's bed upon R1's return from visiting R1's family. However, the administrator stated that R1 resides in the Memory Care Unit and most of the residents wander around the unit but since the incident, they have started locking R1's room when R1 leaves to visit family to prevent this from happening again and R1 did not have any personal items missing from the incident.

After the investigation, this allegation 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 reviewer with the administrator and a copy is provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC9099 (FAS) - (06/04)

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