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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600980
Report Date: 12/07/2021
Date Signed: 12/07/2021 01:10:04 PM

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: 148DATE:
12/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Assistant Executive Director, Siobhan SurracoTIME COMPLETED:
01:45 PM
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On December 7, 2021, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by the Assistant Executive Director, Siobhan Surraco, and the Community Business Director, Seema Chand, joined shortly thereafter. LPA Charitra explained the purpose of the visit and LPA was screened at the front entrance. Facility was able to provide LPA documentation on residents, staff, and visitors screening/temperature log.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident, visitors, and staff daily monitoring records, and 30-day PPE supply. During the visit, LPA observed all staff and most residents to be wearing masks. According to the Business Director, all residents and staff are vaccinated.

LPA observed shared bathrooms to be equipped with paper-towels and liquid soap. LPA advised to post hand-washing signs in the shared bathrooms. All bedrooms are considered resident apartments with a private bathroom included; bathrooms are equipped with non-skid mats, liquid soap, and paper-towels. LPA toured the kitchen and observed sufficient amount of perishable and non-perishable foods.

Medications, toxins and sharps are stored appropriately and inaccessible to residents, and a comfortable temperature is maintained. Lighting is sufficient for comfort. First aid kit was observed to be completed. Extra linen was observed to be present.

LPA requests the following documents to be submitted to CCLD by December 14, 2021:
  • LIC309 Administrative Organization
  • LIC308 Desgination of Administrative Responsibility
  • LIC500 Personnel Report
  • Administrator Certificate
  • LIC610E Emergency Disaster Plan
  • LIC808 COVID Mitigation Plan
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
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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