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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600980
Report Date: 03/30/2021
Date Signed: 07/28/2021 08:11:46 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: 130DATE:
03/30/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Freddie FullonTIME COMPLETED:
03:30 PM
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On this date, Licensing Program Analyst (LPA) Michael Garcia conducted an unannounced case management tele-inspection in response to the March 26, 2021 Unusual Incident Report that the facility had self-reported. Due to the pandemic, the inspection was conducted remotely with Freddie Fullon, executive director/administrator.

Today, LPA interviewed the administrator.

Administrator shall ensure to provide copies of the following documents to LPA, via email, within 24 hours:
- Staff 1 (S1)'s written statement about the alleged incident.
- Signed employee handbook from S1.
- Resident 1 (R1)'s most current physician's report.
- Police report/case number related to the incident.

In addition, please have R1 call LPA as soon as possible and provide confirmation.

An electronic copy of the report was emailed to administrator for signature.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Michael GarciaTELEPHONE: (650) 380-4608
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021
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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