415600980-3-4-2021-14-AS-BCHN-C4VVUP-20210713164502

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600980
Report Date: 03/04/2021
Date Signed: 03/04/2021 04:33:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/20/2019 and conducted by Evaluator Bertha Raygoza

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20190920151601

FACILITY NAME:	ATRIA AT FOSTER SQUARE		FACILITY NUMBER:	415600980
ADMINISTRATOR:	KELLI GREENE		FACILITY TYPE:	740
ADDRESS:	707 THAYER LN		TELEPHONE:	(650) 532-2460
CITY:	FOSTER CITY	STATE: CA	ZIP CODE:	94404
CAPACITY:	216	CENSUS: 90	DATE:	03/04/2021
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Freddie Fullon, Administrator		TIME COMPLETED:	04:21 PM

ALLEGATION(S):

1
2
3
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5
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7
8
9

- Lack of supervision resulting in resident breaking their hip
- Resident suffered falls with injury while in care

INVESTIGATION FINDINGS:

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2
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5
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10
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12
13

THIS IS AN AMENDEMENT OF ORIGINAL ON 2/04/20
Licensing Program Analyst LPA Raygoza conducted an unannounced complaint investigation televisit in regards to the above allegations. LPA met with Freddie Fullon, Administrator and stated purpose of visit.

- Lack of supervision resulting in resident breaking their hip. Based on interviews, of S1, S2, S3 and S4 indicating sufficient staffing at the time of R1's fall. Based on review record of Weekly staff roster schedule with sufficient staffing, the allegation was deemed unsubstantiated.
- Resident has had multiple unexplained falls while in care. During the course of the investigation, based on record review of Needs and Services plan for R1, staff roster schedule with sufficient staff. Based on medical records and incident reports, the allegation was 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 allegations are deemed UNSUBSTANTIATED at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha Raygoza	TELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021

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
CCLD Regional Office, 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
09/20/2019 and conducted by Evaluator Bertha Raygoza

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20190920151601

FACILITY NAME:	ATRIA AT FOSTER SQUARE		FACILITY NUMBER:	415600980
ADMINISTRATOR:	KELLI GREENE		FACILITY TYPE:	740
ADDRESS:	707 THAYER LN		TELEPHONE:	(650) 532-2460
CITY:	FOSTER CITY	STATE: CA	ZIP CODE:	94404
CAPACITY:	216	CENSUS: 90	DATE:	03/04/2021
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Freddie Fullon, Administrator		TIME COMPLETED:	04:21 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

- Tables in facility are a tripping hazard for resident(s)

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

THIS IS AN AMENDEMENT OF ORIGINAL ON 2/04/20
- Tables in facility are a tripping hazard for resident(s). During the course of the investigation it was discovered that the Memory care coffee table was not a necessity therefore was a tripping hazard. The coffee table that R1 tripped on measured 15-3/4 inches in height which is shorter than the standard coffee table height of 16 to 21 inches. The Memory Care replacement coffee table is taller in height with no tripod legs to be tangled/caught in. Surveillance Video depicts R1's foot tangled/caught on table and tripped. Staff interview reiterated R1's foot got caught on coffee table and tripped. Therefore, the allegation was substantiated.

The above allegation is found to be substantiated, meaning that the allegation is valid because the preponderance of the evidence standard has been met.

This report was reviewed with Administrator, Freddie Fullon.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha Raygoza	TELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021

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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 14-AS-20190920151601

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 SQUARE	FACILITY NUMBER: 415600980
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/04/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/15/2021 Section Cited CCR 87568.1(a)(2)	1 2 3 4 5 6 7	87468.1(a)(2) Personal Rights of Residents in All Facilities - Residents in all residential care facilities for the elderly shall have all of the following personal rights: to be accorded safe, healthful and comfortable accommodations, furnishings and equipment.	1 2 3 4 5 6 7	POC - Licensee shall submit a written Plan of Correction (POC) describing the specific actions to be taken to ensure residents shall be accorded safe, healthful and comfortable accommodations. Licensee shall put a plan in place to ensure that furnishing that is a tripping hazard has been addressed. POC to be submitted to CCL Office by due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: R1 was not accorded safe, healthful and comfortable furnishings and equipment. R1 unassisted by walker, tripped over a coffee table, which posses a potential Health, Safety or Personal Rights risk to residents 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: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha Raygoza	TELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2021

LIC9099 (FAS) - (06/04)

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