Atria at Foster Square.

On December 2, 2025, Licensing Program Analyst (LPA) Murial Han conducted an annual inspection. LPA met with administrator, Freddie Fullon and LPA explained the purpose of today's visit. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a 6-floor facility; 1st floor being the entrance to the lobby, 2nd floor for Life Guidance/ Memory Care Unit, kitchen, beauty shop, activity room and other common areas, 3rd-6th for Assisted Living (AL) and Independent Living (IL). All floors have elevators and laundry services. Hot water temperature throughout the facility was measured at 108- 118 degrees F. During the tour, LPA observed staff members conducting varies activities and engaging residents. A comfortable temperature is maintained, and lighting is sufficient for comfort. Medication, chemicals, toxins, and sharps objects were locked and inaccessible to residents. 2 days of perishables and 7 days of nonperishable foods were observed for the residents. Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguishers were last serviced on 9/11/2025. Emergency and fire drill records were observed to be sufficient. A review of (7) resident files was conducted and noted on LIC 858. A review of (6) staff files was conducted and noted on LIC 859. No deficiency is cited today. This report is reviewed and discussed with the administrator and a copy is provided.

On 12/2/2025, Licensing Program Analyst (LPA) Murial Han conducted a case management visit to follow-up on an incident that was reported by the facility. LPA met with the administrator and explained the purpose of today's visit. On 11/18/2025, the facility reported an incident that happened on 11/16/2025 concerning resident #1 (R1) who was transferred to the hospital after staff observed R1 complained about left shoulder pain and could not bear any weight. R1 could not report what happened and denied any recent falls. R1 stayed at the hospital for a few days and returned with diagnosis of fracture. During today's visit, LPA interviewed the administrator who stated that R1 returned from the hospital and is currently under hospice care. The administrator stated that R1 had a private caregiver before and after R1's hospitalization. When the injuries were discovered, R1's private caregiver was on-site. The administrator stated that there was no report that R1 fell recently and R1 denied falling. The administrator also stated that there were no incidents that happened which could have resulted in the injuries. LPA observed R1 who appeared to be comfortable in bed with a private caregiver in the room. R1 did not remember what happened and reported that he/she did not have any pain and was comfortable. No deficiency is cited. This report is reviewed and discussed with the administrator.

On May 13, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management - Incident visit. LPA met with the administrator and explained the purpose of today's visit. On April 25, 2025, the facility reported an incident concerning to resident #1 (R1) and resident #2 (R2) had an unwitnessed fall in their apartment. The facility called 911 and upon arrival of the paramedics, they found unknown medications without a valid prescription in the room. The facility has been in communication with the Foster City Police Department regarding the unknown medications that were found in the room. During today' visit, LPA interviewed the administrator, the resident service director, R1 and R2, conducted a facility tour with the resident service director and collected documents. According to the administrator, R1 and R2 were admitted in September 2024 and both of them have sustained multiple falls since admission. R1 has had 6 falls within 18 days and R2 sustained 6 falls within 21 days. On 4/25/2025, R2 was sent to the hospital due to a fall resulting in a closed fracture of right hip. The administrator reported that the facility has found alcohol and unknown medications in their room. The administrator also stated that the facility has completed several change of conditions and reassessed R1 and R2 after the falls but they continued to fall until they hired a private one on one caregiver. Furthermore, the administrator stated that the facility has issued a 30-day eviction notice due to the falls and safety. According to the resident service director, the facility has reported the falls to the provider and the psychiatrist. They have spoken to R1 and R2 about the contributing factors to their falls and encouraged them to hire a private caregiver for fall prevention. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA interviewed R1 and R2 and both of them are of aware of the multiple falls and the contributing factors. R2 stated that the one on one caregiver has helped significantly with preventing them from falling especially for R1. In addition, R2 expressed that the facility has issued a 30-day eviction notice and they are seeking for new placement. LPA explained the process of the eviction notice to R2. No deficiency is cited. This report is reviewed and discussed with the administrator; a copy is provided.

On September 12, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management visit to follow up on an incident that was reported by the facility. LPA met administrator, Freddie Fullon and explained the purpose of today's visit. On August 1, 2024, the facility reported that resident #1 (R1) was transferred to the hospital due to a change of condition and while at the hospital, R1 verbalized to the hospital staff that he/she was afraid of a caregiver as the caregiver was being unprofessional while caring for R1. Subsequently, the hospital reported to the facility and the facility conducted an investigation, and reported it to the Local Police Department and the Ombudsman. R1 has returned to the facility and the facility has implemented new interventions to ensure R1 feels safe at the facility. During today's visit, LPA met with R1 who stated that everything has improved since meeting with the Administrator and the Resident Service Director. R1 also stated that all the caregivers are very professional and nice. No deficiency is cited today. This report is reviewed and discussed with the Assistant Administrator, Kari Jane and a copy is provided.

The administrator denied the allegation and provided documentation indicating that R1's responsible party was notified on the date of R1's hospital transfer. LPA interviewed another resident's responsible party who stated that he / she was notified by the facility when his/her loved one had a change of condition. Based on observation, interviews and records review, this allegations is deemed to be 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 allegation is UNSUBSTANTIATED. This report is review with the assistant administrator and a copy is provided

The facility directors acknowledged that facility staff locked R1's grooming items such as the toothpaste, and toothbrush for safety reasons but those items did not required to be locked as they are not harmful to the residents and residents shall have access to them when needed. According to facility staff, they locked R1's toiletries such as toothpaste and toothbrush for safety reasons and they were aware that items shall not be locked as they are not harmful to the residents. After the investigation, this allegation is deemed to be substantiated. The facility's action was to ensure resident's safety, however, the toiletries were approved and deemed by the facility to be safe, therefore, it shall not be locked and residents shall have access to their own personal possessions, including but not limiting to their toilet articles. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099D. Failure to correct the deficiencies may result in civil penalties. Report was discussed and reviewed with the administrator. A copy of this report and the Appeal Rights is provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 According to the resident service director and resident service supervisor, R1's functional needs care profiles were developed based on R1's LIC 602, their assessment and staff's observation while providing care to R1 and based on the observation details, R1 needed assistance/queueing with grooming such as tooth brushing even when the toiletries were available for R1, combing hair, etc. In addition, they stated that grooming is not only pertaining to brushing teeth, it also included combing hair, cleaning face, applying deodorant, etc. Furthermore, the resident service director and the resident service supervisor reported that R1's responsible party did not agree with the functional needs care profile for R1 as grooming was triggered resulted in additional monthly fee. Therefore, the facility conducted a meeting with the responsible party and other family meeting to discuss the accuracy of the functional needs care profile. During the meeting, adjustments were made, however, they were not significant enough to reduce the monthly fee. In addition, they stated that the functional needs care profile for R1 was developed according to the feedback from the direct care staff and R1's LIC 602. LPA interviewed 2 facility staff members and both of them reported that R1 needed queuing with brushing his/her teeth on a daily basis and sometimes needed assistance. They also reported that they assisted R1 with other grooming tasks such as combing hair, cleaning face, washing hands, etc. Based on documents provided by the facility and the reporting party, R1 had a change in health condition in January and resulted in hospitalization. Prior to R1's return, on January 30, 2024, the resident service supervisor conducted a preplacement appraisal. Upon R1's return, on February 1, 2024, the facility developed R1's Functional Needs Care Profile based on R1's LIC 602. On February 7, 2024, R1's Functional Needs Care Profile was revised and a meeting was held with R1's responsible party, other family members and facility directors to discuss R1' Functional Needs Care Profile as R1's responsible party disagreed with some of the tasks that were triggered. Based on the R1's care log that was completed by the direct care staff members, it revealed that R1 needed assistance with grooming such as dressing, brushing teeth, combing hair, etc. Based on interviews, observation and record review during the investigation, this allegation is deemed to be unsubstantiated as the facility conducted necessary appropriate steps to evaluate R1 prior to admission and revised the Functional Needs Care Profile for R1 accordingly. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Regarding to allegation of- staff do not ensure resident is accorded privacy in personal accommodations, the reporting party stated that when R1 returned from visiting with family, there was another resident found laying R1's bed. The administrator acknowledged that another resident was found on R1's bed upon R1's return from visiting R1's family. However, the administrator stated that R1 resides in the Memory Care Unit and most of the residents wander around the unit but since the incident, they have started locking R1's room when R1 leaves to visit family to prevent this from happening again and R1 did not have any personal items missing from the incident. After the investigation, this allegation is deemed to be 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 allegation is UNSUBSTANTIATED. This report is reviewer with the administrator and a copy is provided.

On December 26, 2023 Licensing Program Analyst (LPA) Murial Han conduct an annual inspection. LPA met with administrator, Freddie Fullon and explained the purpose of today's visit. Administrator provided a tour of the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a 6 floor facility; 1st floor being the entrance to the lobby, 2nd floor for Life Guidance (LG) residents and common areas, 3rd-6th for Assisted Living (AL) and Independent Living (IL). All floors have elevators. Medications are locked in the medication rooms and inaccessible to residents in care. A comfortable temperature is maintained between 71- 74 degrees F and lighting is sufficient for comfort. Chemicals, toxins, and sharps objects were locked and inaccessible to residents. 2 days of perishables and 7 days of nonperishable foods were observed for the residents. Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher was last serviced on 8/3/2023. Fire drill records observed to be sufficient. Egress delay door in the Life Guidance unit was tested to be adequate. Hot water temperature through-out the facility is measured at 106- 111 degrees F. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA reviewed 5 resident records and all of them contained admission agreement, medical assessment- LIC 602 (Physician Order), Appraisal Needs and Service Plan, admission agreement, Resident Identification information, Pre-appraisal assessment, etc. LPA reviewed 5 staff files and all of them contained personnel records, health screening, COVID-19 vaccination information, Job Description, Abuse Statement, First Aide/CPR, Criminal Record Statement, fingerprint cleared and associated to the facility. No deficiency is cited. This report is reviewed and discussed with the administrator; a copy is provided.

As part of the investigation, LPA interviewed the business office manager and reviewed documents. According to the business office manager, the facility did not charge the reporting party for pre-admission fee as the facility also refer to it as the New Resident Services Fee. In addition, the business office manager stated that the money that was paid to the facility covered the monthly rent. Based on the Atria At Foster Square Resident Account Summary, the New Resident Service Fee was credited. Based on the admission agreement provided by the facility, under Term, it stated that this agreement will become effective on the Move In Date listed on the Agreement which was 2/28/2023 and the admission agreement was signed on 2/27/2023. In addition, under termination by you at anytime, it stated that the facility shall be provided a 30 calendar days prior to the date of the termination. After the investigation, this allegation is deemed to be unfounded as the pre-admission fee was not charged. The amount that was paid by the reporting party was used for the monthly rent. 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 Business Office Manager and a copy is provided.

Based on documentation provided, facility called third-party HVAC vendor who arrived to the facility on 12/19/22, to diagnose the heating units that were not in working condition. According to documents reviewed, HVAC vendor came to the facility between 12/19/22 through 5/17/23 to troubleshoot and repair the heating units at the facility, in addition to additional damages and issues that were observed by the contractors. According to the administrator, the heating units were on and off due to other damages that were discovered by HVAC vendor, however administrator and HVAC were in contact daily by phone or in person. According to 3/3 residents who did not have a working heating unit, they indicated that they were comfortable, staff checked on them, and they were provided with space heaters in case they needed it. On 10/6/2023, LPA toured four rooms that did not have working heating units during the winter storms. Heating and cooling unit was observed to be in good working condition. Therefore, based on the documents reviewed, information reviewed, and interviews conducted, the allegations above are UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Report is reviewed with Administrator and a copy is provided.

On September 13, 2023, Licensing Program Analyst (LPA), Murial Han conducted an announced case management visit to follow up on an incident that was reported by the facility. LPA met with administrator and explained the purpose of today's visit. On September 7, 2023, facility reported to CCL that resident #1 (R1)'s responsible party reported to the facility that on September 1, 2023, R1 left the facility, went for a walked and returned. Facility staff reviewed the video footage and discovered that R1 exited the facility through the back elevator, and returned within 15 minutes. During today's visit, LPA toured the route of how R1 exited the facility, interviewed R1 and the responsible party, administrator, resident service director and resident service coordinator. Based on the incident report, it was indicated that R1 has diagnosis of dementia and is unable to leave the facility unassisted. However, based on R1's physician's report dated on May 10, 2023, R1 was not at risk for leaving the community unsupervised and this was verified in the presence of the administrator. According to R1, he/she took the elevator down, got off in the garage, pressed the button to open the garage door, and left. R1 stated that he/she was not lost, not scared, walked around the facility and returned in a few minutes. As part of R1's service plan, facility will continue to check on R1 every 2 hrs. No deficiency cited today. This report is reviewed and discussed with the administrator. A copy is provided.

Regarding the allegation that staff left resident in bed for long periods of time, according to the reporting party, R1’s room smelled like urine. During the investigation, LPA interviewed the administrator and reviewed R1's file. The administrator denied this allegation and indicated that R1 was independent and did not require toileting assistance, however R1 was verbal and if he/she needed assistance, the facility staff would assist with toileting. Based on R1's needs and service plan, R1 was independent in the mechanics of toileting. In addition, based on R1's physicians report, R1 was able to care for his/her own toileting needs. Based on the information collected and interviews conducted ,although the above allegation may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with the administrator and a copy is provided.