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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600980
Report Date: 01/20/2021
Date Signed: 01/25/2021 08:08:14 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ATRIA AT FOSTER SQUAREFACILITY NUMBER:
415600980
ADMINISTRATOR:FREDDIE FULLONFACILITY TYPE:
740
ADDRESS:707 THAYER LNTELEPHONE:
(650) 532-2460
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY:216CENSUS: 115DATE:
01/20/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Freddie FullonTIME COMPLETED:
02:10 PM
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On this date, Licensing Program Analyst (LPA) Michael Garcia conducted a Case Management tele-visit to provide Technical Assistance (TA) to the facility regarding COVID-19 with the assistance from Paul Portem, MSN, RN, program clinical consultant. The tele-visit was conducted with Freddie Fullon, executive director/administrator.

According to the administrator, there is no active COVID-19 case at the facility at this time. A staff, private duty aide, and a resident tested positive for COVID-19 early this month and all cases have been resolved. The facility has contacted the San Mateo County Public Health for assistance regarding mass testing and waiting for schedule. The facility has conducted contact tracing at this time.

The TA visit resulted with the following recommendations:
- Continue to work with Local Public Health for mass testing.

Administrator shall ensure to submit a signed and dated action plan regarding the above recommendations to LPA, via email, within 24hrs.

Report was emailed to Allen Chin, assistant administrator, for signature.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Michael GarciaTELEPHONE: (650) 380-4608
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2021
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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