415600980-4-4-2023-14-AS-CSMH-CQVTZ8-20230414150956

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600980
Report Date: 04/04/2023
Date Signed: 04/04/2023 01:38:08 PM

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
11/09/2022 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20221109113420

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: 145	DATE:	04/04/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Freddie Fullon		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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- Staff mismanaged resident medication

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver findings regarding the allegations received. LPA met with administrator Freddie Fullon and explained the purpose of today's visit.

During the course of the investigation it was discovered that the time period in question, around June 2022, there was a COVID outbreak which impacted staffing. With the administrator, LPA Vado reviewed medication logs, and discussed staffing issues due to COVID. It was confirmed that in the morning hours of a day in June 2022 there were no available med techs due to them calling out the morning at the start of their work shifts due to COVID symptoms. Administrator confirmed that memory care residents did not receive medications until back up staff arrived later that morning. Other staff were in place so there was not a lack of supervision. This allegation is substantiated.

Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D. Report is reviewed with administrator.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

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

LIC9099 (FAS) - (06/04)

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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
11/09/2022 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20221109113420

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: 145	DATE:	04/04/2023
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Freddie Fullon		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

- Staff did not report an incident as required

INVESTIGATION FINDINGS:

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2
3
4
5
6
7
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12
13

On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver findings regarding the allegations received. LPA met with administrator Freddie Fullon and explained the purpose of today's visit.

During the investigaiton LPA was able to determine that due to a COVID there was a lack of staff at the time frame in discussion around June 2022 in the morning hours for that one day. Records show that reporting was taking place regarding the COVID outbreak. A staffing plan was in place and utilized by the facility to the best of their abilities. This allegation is unfounded.

This agency has investigated the complaint alleging, staff did not report an incident as required. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. No citations issued. Report reviewed with administrator Freddie Fullon.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20221109113420

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: 04/04/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/05/2023 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care- If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.	1 2 3 4 5 6 7	Facility shall develop a plan of correction (POC) to ensure compliance with Sec.87465(c)(2). Licensee shall ensure in writing that all physicains order and prescritions are followed per the order or prescription. Medication training is to be provided.
	8 9 10 11 12 13 14	This regulation has not been met as evidenced by: Per the discovery made, med techs around June 2022 were not available due to COVID symptoms and illness on the day of their work shift so they could not go to work. It was identified that in that morning hours the residents in memory care did not receive medications.	8 9 10 11 12 13 14	LPA is to receive plan via mail regarding.
	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: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC9099 (FAS) - (06/04)

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