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.

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

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 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.

Regarding the allegation that facility staff did not follow admission agreement, according to the reporting party, the facility required R1's responsible party to pay for the month of November after facility was notified on 10/28/22 that R1 will not be returning to the facility. During the investigation, LPA reviewed the facility's admission agreement. According to the admission agreement, the responsible party can terminate the agreement at any time by providing the facility a written notice of termination at least 30 days prior to the date of the termination stated in the notice. In addition, the admission agreement indicates that the responsible party will be responsible of all fees and expenses incurred during the 30-day notice period. Based on documentation reviewed, on 10/28/22, R1's responsible party provided the facility with a notice indicating that R1 will not be returning back to the community and that all of R1's belongings will be picked up by 10/31/22. Furthermore, on 10/31/22, the administrator emailed the responsible party back indicating a 30-day notice would have to take place from 10/28/2022, and called to notify the responsible party that R1 may return back to the community. Regarding the allegation that facility staff photographed resident without consent and facility staff shares resident’s confidential information to a non-authorized party, according to the reporting party, a staff member took photos on their phone of R1’s accidents and shared the photos with an individual who came to visit R1. During the investigation, LPA reviewed R1’s files, reviewed staff roster and staff schedules, and interviewed the administrator and the witness. Based on the file reviewed, LPA observed a copy of the facility's photo/video consent form signed by R1's responsible party. Based on the interview conducted with the witness, it was indicated that a staff showed him/her pictures of R1’s incontinent accidents. LPA reviewed the staff roster, and the staff schedules for the dates that was provided by the witness, however there was no staff member that fit the name or description as identified by the witness. According to the administrator, the facility staff takes photos or resident’s accidents to report to the Administrator, resident’s responsible parties or the physician. Therefore, based on the documents collected, 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 Executive Director, Freddie Fullon and a copy is provided.

On 2/2/23, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced visit and met with the Administrator, Freddie Fullon and explained the purpose of the visit. The purpose of today's visit is to deliver an immediate exclusion letter to exclude an employee of the facility. The letter was given and reviewed by the administrator. This report is reviewed and discussed with administrator. A copy is provided.

On December 9, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. LPA observed the COVID-19 signage posted at the front entrance. LPA signed in and was screened at entry point via digital screening monitor. LPA met with Executive Director, Freddie Fullon and explained the purpose of the visit. Executive Director was able to show LPA daily monitoring for staff, visitors, and residents on their digital system called Accushield which is also used to sign in and out. LPA toured 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, 3rd-6th for Assisted Living (AL) and Independent Living (IL). All floors have elevators. LPA observed elevators are level to the ground and easy access for residents with walkers and wheel chairs. LPA observed the dining room and lounge area on the second floor to be clean and free from any tripping hazards. During the visit, there was a Jewish spiritual gathering and residents were observed to be maintaining social distancing. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable. Dining room was observed to have tables 6ft apart from each other. Communal bathrooms on lobby and 2nd floor were equipped with liquid soap, paper-towels, and a trash can with a fitted lid. Wellness room was observed on the 2nd floor with PPE supplies and medication room was observed to be locked and inaccessible to residents. Chemicals and toxins in LG has been secured in a locked cage and chemicals and and toxins in AL/IL are stored appropriately and inaccessible to residents. A comfortable temperature between 71-74 degrees F is maintained throughout the facility. LPA observed a total of five laundry rooms; 1 in the garage, 1 in LG, and 3 in AL/IL. According to the Administrator, only staff have access to the laundry rooms in the garage and LG. Residents in AL and IL bring their own detergent. Bleach is not allowed on facility premises. Overall, the community was clean, sanitary and odorless. Infection control practices are observed: entry procedures, daily monitoring log for staff, residents and visitors, 30-day PPE supply, face coverings for staff, containment strategies, staff training and policies. LPA requests the following forms to be submitted to CCLD by 12/16/22: LIC308 Designation of Administrative Responsibility LIC500 Personnel Report LIC610E Emergency Disaster Plan Administrator Certificate

Page 2 - LIC9099C When speaking to both the RSD/nurse and the administrator, if a resident cannot self feed at any point then the responsible party for that resident has to acquire outside help to provide that one on one feeding to that specific resident. Upon review of the admission agreement, and specific to memory care, it is outlined that one on one feeding is not provided by the facility. The facility is providing food but is not providing one on one, or hand to mouth, feeding of residents in memory care. Due to these discoveries the allegation is unsubstantiated. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.

On September 28, 2022, Licensing Program Analyst (LPA) Komal Charitra, conducted an unannounced case management visit to follow up on an incident that was reported to CCLD on June 23, 2022. LPA met with Administrator, Freddie Fullon and explained the purpose of the visit. The Licensee reported on 6/23/22, resident #1 (R1) AWOL (Absent Without Official Leave). During the visit, LPA reviewed R1's file and interviewed staff. According to the files reviewed, R1 has a diagnosis of dementia and is not able to leave the facility unassisted. Furthermore, LPA reviewed R1's needs and service plan and upon admission R1 was on status checks and escorting for transition to the community. On 6/28/22, R1's needs and service plan addressed R1's confusion, impaired judgement, and risk of elopement and the facility's intervention upon admission was ensuring a private caregiver was assigned to R1 for about 2 months and ensured there was frequent communication with R1's Geriatric specialist. According to the Administrator, R1 was seen in the dining room hall around 8:15am and at 9:30am, it was reported by Med-Tech that R1 was unable to be located. Staff searched the entire community and the premises. In addition, it was indicated that community directors searched by car within 10 miles radius and found R1, about 3 miles away from the facility. According to the Administrator, after this incident occurred, all required parties were notified and a private caregiver was assigned to R1 till R1 moved into a secure environment. Based on interviews and file reviewed during the visit, the facility did attempt to ensure basic services were being met for R1. No citations will be issued at this time. Report is reviewed with Administrator, Freddie Fullon and a copy is provided.

The allegation that facility staff fails to communicate with resident’s authorized representative refers to the facility failing to report R1’s hospitalization to designated R1’s responsible party. According to the administrator, R1 had a change of condition during the night of 8/30/2021 and early hours of 8/31/2021. Staff #1 (S1) on the night shift was not familiar with the local responsible party listed in the contact list, and instead called one of the emergency contacts who lives in Florida, and who was unable to readily attend to R1’s emergency. Since this incident, the administrator reported that the facility has revised R1's contact sheet and added R1's responsible party under emergency contact. Section 87468.1 (a) (8) Personal Rights of Residents in All Facilities states that residents in all residential care facilities for the elderly shall have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. By failing to maintain an accurate record, the facility failed to notify the responsible party when R1 was transferred to the hospital. Therefore, based on the above information, interviews and record review, this allegation is substantiated Based on interviews, observations and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, these 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. A copy of 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 The sequence of events indicates that late on 8/30/2021, the resident had an anxiety attack. The facility called emergency services early on 8/31/2021. There was a caregiver (S1) with the resident when paramedics arrived. The resident was then transported to the hospital. EMS records did not note any incidents during transfer or at the hospital. However, once at the hospital it was discovered that the resident had a right shoulder fracture, spleen laceration, and left buttocks bruising consistent with traumatic injuries. The injuries could had been caused by a fall, or cardio embolic source, but medical personnel were unable to rule any possibility out. The Department has been unable to interview the caregiver (S1) who was with the resident until the EMS arrived, and who could provide information on about what could had happened. The Administrator has also proven uncooperative. Base on record review and interviews during the course of investigation, this allegation is unsubstantiated. Although the above investigations 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 facility's Administrator. A copy is provided.

On 3/29/2022, Licensing Program Analysts (LPA) Murial Han conducted an unannounced case management visit to follow-up on a complaint investigation. LPA Han met and explained the purpose of the visit with the assistant administrator, Siobhan Surracao while the administrator, Freddie Fullon was busy at the moment then the administrator took over and assisted with the rest of the visit. The Department investigated allegations under complaint # 14-AS-20210913142555, regarding a resident sustaining a fracture while in care; facility refusing to accept resident back to the facility; and facility failing to report/provide information to the injured resident’s family. During the course of investigating the allegation of the resident sustaining a fracture while in care, there was a caregiver (identified as S1 in complaint 14-AS-20210913142555) who was with the resident #1 (R1) prior to the resident being removed by emergency personnel. Upon arrival to the hospital, R1 was found to be suffering of a right shoulder fracture, spleen laceration, and left buttocks bruising consistent with traumatic injuries. S1 has failed to cooperate with the Department investigation. During the course of investigating the allegation, the department asked the administrator to provide camera footage to the Department to determine who was with the resident when the paramedics arrived, and who could had been present before removal of the resident by the paramedics. The administrator failed to provide the actual footage despite numerous requests to do so. A resident went to the hospital early in the morning of 8/31/2021. After a stay at the hospital for couple of weeks, the resident was discharged back to the facility on 9/9/2021. According to the administrator and the resident service director, R1 was readmitted with health conditions and needs that were not previously required and the facility was not capable of caring for R1 under these new health conditions. Therefore, the administrator gave R1, as only options, to stay as long as R1’s responsible party hire a personal skill professional to care for the resident, or to have R1 transferred back via ambulance to the hospital. 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 The administrator illegally evicted a resident when failing to follow Section 87224. The licensee failed to reappraise a resident before admitting him/her back from a hospital stay; then, upon readmission, the resident was cursorily deemed beyond the level of care (without a formal appraisal) and sent back to the hospital. The facility has been cited on a LIC 9099D under complaint number 14-AS-20210913142555. A resident had a change of condition during the night of 8/30/2021 and early hours of 8/31/2021. The facility had failed to update the resident’s emergency card, so the notification of the resident’s condition went to a contact person out of State, and who unable to respond to the resident’s situation and in so doing violating Section 87468.1 (a) (8) Personal Rights of Residents in All Facilities. The facility has been cited on a LIC 9099D under complaint number 14-AS-20210913142555. Given the above information the facility is cited under: · 87755 (b) Inspection Authority of the Licensing Agency - The licensee shall ensure that provisions are made for private interviews with any resident or any staff member; and for the examination of all records relating to the operation of the facility. · 87755 (c) Inspection Authority of the Licensing Agency - The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed, if necessary, for copying. · 87405 (d) (2) Administrator - Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to the applicable laws, rules and regulations. · 87411 (a) Personnel Requirements – General - Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs . In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. Based on interviews and record reviews during the investigation, deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with the administrator. A copy is provided.

On 3/29/2022, Licensing Program Analysts (LPA) Murial Han conducted an unannounced plan of correction (POC) visit to verify and to confirm that the facility is in compliance with the citation that was issued on 3/8/2022. LPA Han met and explained the purpose of the visit with the assistant administrator, Siobhan Surracao while the administrator, Freddie Fullon was busy at the moment then the administrator took over and assisted with the rest of the visit. On 3/8/2022, the facility received a citation for not providing medical record to the responsible party as requested and the plan of correction was due on 3/22/2022 that required the facility to provide the following documents to the responsible party and a copy to Community Care Licensing (CCL). - 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. - R1's diagnosis and facility documentation related to the ambulance transportation on 9/9/2021. As of 3/29/2022, the facility has not submitted any proof to CCL that the plan of correction was completed and the responsible party has not received any documents from the facility..Therefore, CCL is reissuing the citation and assessing for civil penalty of $100 per day between 3/23/2022- 3/28/2022 in the amount of $600. Civil penalty will continue at $100 per day starting from 3/29/2022 until the plan of correction is completed. Based on information above, deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809D. Failure to correct the deficiencies will result in additional civil penalties. This report is discussed and reviewed with the administrator. A copy is provided.

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

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.