415600980-12-10-2024-14-AS-MHAN-DBTSZZ-20241210131957

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600980
Report Date: 12/10/2024
Date Signed: 12/10/2024 06:33:32 PM

Document Has Been Signed on 12/10/2024 06:33 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 SQUARE		FACILITY NUMBER:	415600980
ADMINISTRATOR/ DIRECTOR:	FREDDIE FULLON		FACILITY TYPE:	740
ADDRESS:	707 THAYER LN		TELEPHONE:	(650) 532-2460
CITY:	FOSTER CITY	STATE: CA	ZIP CODE:	94404
CAPACITY: 216	TOTAL ENROLLED CHILDREN: 0	CENSUS: 144	DATE:	12/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Community Business Director, Seema Chand		TIME VISIT/ INSPECTION COMPLETED:	01:30 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 10, 2024 Licensing Program Analyst (LPA) Murial Han conduct an annual inspection. LPA met with Community Business Director, Seema Chand and explained the purpose of today's visit. The Community Business Director and the Maintenance Director 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 and laundry services. Medications are locked in the medication rooms and inaccessible to residents in care. A comfortable temperature is maintained 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 extinguishers were last serviced on 11/24/2024. Emergency drill records observed to be sufficient. Hot water temperature through-out the facility was measured at 106- 118 degrees F. During the medication review, LPA interviewed med tech (S1) regarding to the facility’s medication destruction process and the participants. He/she stated that the facility would complete the Medication Destruction Record and if it was non-Narcotic medication, it would be witnessed by a designated staff and another adult who was not a resident and if it was narcotics, it would be the administrator and the resident service director.

April Cowan	TELEPHONE: (650) 266-8889
Murial Han	TELEPHONE: (619) 209-9761
	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

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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Document Has Been Signed on 12/10/2024 06:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87465 Incidental Medical and Dental Care This requirement is not met as evidenced by: Based on observation, interview and records review, the facility was not able to provide documentation to proof that the administrator was one of the participants for the Medication Destruction Process.
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility was not able to provide documentation to proof that the administrator was one of the participants for the Medication Destruction process. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/18/2024
	Plan of Correction
1 2 3 4	The administrator will provide a plan in writing to ensure compliance with the Regulation. The administrator will provide a copy of the plan to CCL by 12/18/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

April Cowan	TELEPHONE: (650) 266-8889
Murial Han	TELEPHONE: (619) 209-9761
	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/10/2024 06:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87705 Care of Persons with Dementia This requirement is not met as evidenced by: Based on observation and interview, LPA observed handsoap bottles for room 209B and 218B were not in their own possession as they were left unattended in the shared bathrooms.
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed handsoap bottles for room 209B and 218B were not in their own possession as they were left unattended in the shared bathrooms which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/11/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan in writing to ensure compliance and the plan shall indicate staff education. The administrator will submit a copy of the plan to CCL by 12/11/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

April Cowan	TELEPHONE: (650) 266-8889
Murial Han	TELEPHONE: (619) 209-9761
	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/10/2024

NARRATIVE

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According to the documentation provided by the facility, LPA observed the medication destruction records (both non-Narcotic and Narcotic Medications) for resident #1 (R1) did not have the administrator’s signature on it. In addition, the med tech confirmed that the signatures on the records were not the administrator.

During the tour, at 10:20am in the Life Guidance Unit (Memory Care Unit), LPA observed personal grooming and hygiene items were not in resident's own possession as LPA observed a bottle of the Free & Clean hand wash soap bottle in room 209 and 218's shared bathrooms that were labeled for 209B and 218B.

A review of (5) resident files was conducted and noted on the LIC 858.
A review of (5) staff files was conducted and noted on the LIC 859.

The following documents were requested submitted to CCL by 12/18/2024:
- Liability Insurance and the administrator certification

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the Community Business Director. A copy of this report and the appeal rights were provided.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC809 (FAS) - (06/04)

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