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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600980
Report Date: 03/08/2022
Date Signed: 03/08/2022 02:09:24 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
12/22/2021 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20211222132753
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: 146DATE:
03/08/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator, Freddie FullonTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Licensee failed to provide documentation regarding the circumstances related to the injuries to he responsible party
INVESTIGATION FINDINGS:
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On 3/8/2022 , Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20211222132753. LPA Han was screened at the front entrance. LPA Han met with the Administrator, Freddie Fullon and explained the purpose of the visit.

Regarding to Licensee failed to provide documentation regarding the circumstances related to the injuries to the responsible party- the reporting party stated that shortly after resident #1 (R1)'s passing in 2021, the reporting party contacted the facility several times requesting for R1's medical records and no one from the facility has contacted the reporting party back. Under section 87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (9)To have communications to the licensee from their representatives answered promptly and appropriately. As of 3/8/2022 , the reporting party has not received the documents that was requested in September 2021. Therefore, the facility did not ensure the communications from the licensee to the responsible party was answered promptly and appropriately.

The following documents were requested by the responsible party:
- A list of Medication that was administered from 8/30/21- 8/31/21
- Documentation related to the hospital transfer on 8/31/21
- The assessment/service plan that was conducted by the resident service director and the responsible party including the times that R1 would be checked on by staff and the documentation of who and when R1 was checked on.
- A list of the times that R1 was checked on as shown on the camera footage from 8/30/21 7PM- 8/31/21.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
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 4
Control Number 14-AS-20211222132753
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
VISIT DATE: 03/08/2022
NARRATIVE
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Additional new request from the responsible party:
- R1's diagnosis and facility documentation related to the ambulance transportation on 9/9/2021.

Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations 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.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 14-AS-20211222132753
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: 03/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2022
Section Cited
CCR
87468.1(a)(9)
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PERSONAL RIGHTS OF RESIDENTS....(a)Residents in all residential care facilities....(9) To have communications to the licensee from their representatives answered promptly and appropriately.
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The facility shall provide all the documents that are stated on the LIC9099 to the responsible party and a copy to CCL by 3/22/22.
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This requirement was not met as evidenced by: the facility failed to provide R1's medical records as requested by the responsible party promptly and appropriately as requested which posed potential health and safety risks to resident in care.
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The administrator will review this regulation and submit a statement of acknowledgment after the review by the plan of correction due date 3/22/2022.
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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 MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
12/22/2021 and conducted by Evaluator Murial Han
COMPLAINT CONTROL NUMBER: 14-AS-20211222132753

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: 146DATE:
03/08/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Administrator, Freddie FullonTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Questionable death - Resident died of injuries caused by physical abuse
INVESTIGATION FINDINGS:
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On 3/8/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20211222132753. LPA Han was screened at the front entrance. LPA Han met with the Administrator, Freddie Fullon and explained the purpose of the visit.

During the investigation, the Department conducted interviews, reviewed and collected resident #1 (R1)'s medical records.

Regarding the allegation concerning questionable death- the Department found no evidence that the resident died at the facility due to questionable death as the immediate cause death was list on the death certificate to be Cerebrovascular Disease.

Based on the above information, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis.

This report is reviewed and discussed with the administrator. A copy is provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4