415600980-11-22-2021-14-AS-KHOS-C9JN2X-20211209090528

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600980
Report Date: 11/22/2021
Date Signed: 11/22/2021 01:29:19 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
10/19/2021 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20211019114209

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: 148	DATE:	11/22/2021
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Resident Service Director, Angel Bustos		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Facility is not meeting resident's dietary needs

INVESTIGATION FINDINGS:

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On 11/22/2021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-2021101911429. LPA Han was properly screen at the front entrance. LPA Han met with the Resident Service DIrector, Angel Bustos and explained the purpose of the visit.

Regarding to allegation of facility is not meeting resident's dietary needs, according to the hospital's record, it did not indicate that Resident #1 (R1) required a special diet upon returned to the facility, however, according to the facility staff, the Reporting Party requested R1's food to be cut and this request was incorporated in the Resident Functional Needs Assessment after the hospitalization. To ensure this request was followed, the facility staff stated that R1's meals were pre-cut from the kitchen then served. The Reporting Party provided a photo of a meal showing a piece of meat on the plate that was not pre-cut prior to serving, however, there was no indication on the photo illustrating that it was taken after this request was made. In addition, there was no information forthcoming from R1's private caregiver who the Reporting Party stated that witnessed the pre-cut meat.

Base on record review and interviews during the course of investigation, this allegation is unsubstantiated.

Although the above allegation 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 allegation is UNSUBSTANTIATED.

Exit interview conducted with the Resident Service Director. A copy is provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3

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
10/19/2021 and conducted by Evaluator Murial Han

COMPLAINT CONTROL NUMBER: 14-AS-20211019114209

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:	DATE:	11/22/2021
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Resident Service Director, Angel Bustos		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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9

Staff are not providing supervision per doctors orders

INVESTIGATION FINDINGS:

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5
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7
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13

On 11/22/2021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-2021101911429. LPA Han was properly screen at the front entrance. LPA Han met with the Resident Service DIrector, Angel and explained the purpose of the visit.

Regarding to allegation of- staff are not providing supervision per doctor's order, the Reporting Party stated that a few days after Resident #1 returned from the hospital, there was a virtual follow-up appointment with R1's Nurse Practitioner, and during the appointment, the Nurse Practitioner ordered R1 to receive supervision during meals due to R1's recent change in health condition but it was not carried out. The Facility Director acknowledged that such order was not carried-out as the facility was not aware of it. However, according to Staff #1 (S1) who participated in the virtual appointment acknowledged that this order was given by the Nurse Practitioner during the virtual appointment. R1 was discharged from the facility 2 days later.

LPA Han reviewed the Appointment Detail Report from the Nurse Practitioner and it revealed that R1 needed supervisor with meals.

Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation is were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator, and Appeal Rights provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021

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 3

Control Number 14-AS-20211019114209

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: 11/22/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/06/2021 Section Cited CCR 87611(e)	1 2 3 4 5 6 7	87611 GENERAL REQUIREMENT FOR ALLOWABLE HEALTH CONDITIONS..(e)In addition to Sections 87465(a).. the licensee shall ensure that the resident is cared for in accordance with the physician's orders..This requirement was not met as	1 2 3 4 5 6 7	The Administrator and/or designee will provide in-service to staff regarding this requirement and will provide a copy of the in-service lesson plan and staff sign-in sheet to the Regional Office by the due date 12/6/2021.
	8 9 10 11 12 13 14	evidenced by: the facility failed to carry-out R1's Nurse Practitioner's order to provide supervision during meals due to a recent change in health condition which posed potential health and safety risks to resident 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: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021

LIC9099 (FAS) - (06/04)

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