Inspection Reports for Atria at Foster Square

The inspection was an unannounced Case Management - Incident visit triggered by a reported incident involving two residents who had unwitnessed falls and the discovery of unknown medications without valid prescriptions in their apartment.

The facility reported multiple falls for two residents since their admission, including a fall resulting in a closed fracture of the right hip. The facility found alcohol and unknown medications in the residents' room, communicated with police, and issued a 30-day eviction notice due to safety concerns. No deficiencies were cited during the visit.

The visit was complaint-related due to an incident reported on April 25, 2025, involving unwitnessed falls of two residents and the presence of unknown medications without valid prescriptions. The facility has been in communication with the Foster City Police Department regarding the medications. The complaint was investigated and no deficiencies were cited.

The inspection was an unannounced annual inspection conducted to evaluate compliance with licensing regulations and assess the facility's operations and safety.

The inspection found deficiencies related to the medication destruction process documentation lacking the administrator's signature and personal grooming items not being in residents' possession in the memory care unit. The facility was otherwise compliant with safety measures such as fire safety, medication security, and food provisions.

An unannounced Case Management visit was conducted to follow up on an incident reported by the facility involving a resident's concern about a caregiver's unprofessional behavior.

The facility investigated the incident, reported it to the Local Police Department and Ombudsman, and implemented new interventions to ensure the resident feels safe. During the visit, the resident stated that conditions have improved and caregivers are professional. No deficiencies were cited.

The visit was triggered by a reported incident where a resident was afraid of a caregiver due to unprofessional behavior. The facility conducted an investigation and reported it to authorities. The resident confirmed improvement and safety measures in place.

An unannounced complaint investigation visit was conducted in response to allegations received on 2024-06-27 regarding staff not ensuring resident records contain correct information, charging residents for services not rendered, and failure to report incidents to appropriate parties.

The investigation substantiated that resident #1's date of birth was incorrect on the facesheet, posing a potential health risk. The allegations that staff charged a resident for services not rendered and failed to report an incident to appropriate parties were found to be unsubstantiated.

The complaint investigation was substantiated for the allegation that staff did not ensure resident's records contained correct information. The allegations that staff charged resident for services not rendered and did not report an incident to appropriate parties were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not allow resident direct access to personal grooming and hygiene items, and that the licensee did not abide by the terms of the resident's admission agreement.

The investigation substantiated that the facility locked resident #1's grooming items such as toothpaste and toothbrush, which violated residents' personal rights to access their own possessions. Another complaint regarding inappropriate evaluation of resident service needs was unsubstantiated after review of care profiles and interviews. A privacy allegation was also unsubstantiated as the facility took corrective actions.

The complaint investigation was substantiated for the allegation that staff locked resident #1's grooming and toileting items, violating the Admission Contract and residents' personal rights. The allegations that staff did not appropriately evaluate resident's service needs and did not ensure privacy were unsubstantiated.

The visit was an annual unannounced inspection conducted by Licensing Program Analyst Murial Han to evaluate the facility's compliance with regulatory requirements.

The inspection found no deficiencies. The facility was toured, safety measures were verified, resident and staff records were reviewed and found complete, and all safety equipment and protocols were adequate.

The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was not refunding a pre-admission fee.

The investigation found that the allegation was unfounded. The facility did not charge a pre-admission fee but referred to the payment as a New Resident Services Fee, which was credited and used to cover monthly rent according to the resident account summary and admission agreement.

The complaint alleged that the facility was not refunding a $9,100 pre-admission fee paid to secure a room. The investigation determined the allegation to be unfounded as the fee was not charged and the payment was applied to monthly rent.

The inspection was an unannounced complaint investigation visit triggered by complaints received on 2023-04-25 regarding failure to provide comfortable temperature, facility disrepair, unsafe environment, and failure to issue a refund.

The investigation found the allegations of failure to provide comfortable temperature, facility disrepair, and unsafe environment to be unsubstantiated as the facility took steps to provide space heaters and repair heating units. The allegation of failure to issue a refund was found to be unfounded as a refund was confirmed to have been provided to the resident.

The complaint investigation was unannounced and involved allegations that staff failed to provide comfortable temperature, the facility was in disrepair, staff failed to provide a safe and comfortable environment, and staff failed to issue a refund. The heating units were in disrepair from December 2022 to May 2023, but space heaters were provided and repairs were ongoing. Refund to Resident 1 was confirmed. The allegations were determined to be unsubstantiated or unfounded.

The visit was a case management follow-up on an incident reported by the facility involving a resident who left the facility unassisted.

The investigation found that the resident exited the facility through the back elevator and returned within 15 minutes. The resident was not at risk for leaving unsupervised according to a recent physician's report. No deficiencies were cited during this visit.

The visit was triggered by an incident report regarding resident #1 leaving the facility unassisted. The resident has dementia but was determined not to be at risk for unsupervised exit based on a physician's report dated May 10, 2023.

An unannounced complaint investigation visit was conducted in response to allegations received on 2022-09-02 regarding multiple falls, failure to observe changes in a resident's condition, untimely medical attention, and prolonged bed rest of a resident.

The investigation found that although the resident had multiple falls, the facility sought timely medical attention and communicated with the resident's physician and responsible party. The allegation that staff left the resident in bed for long periods was unsubstantiated due to lack of evidence. Overall, the allegations were determined to be unsubstantiated.

The complaint involved allegations that a resident had multiple falls, staff did not observe changes in the resident's condition, staff did not seek timely medical attention, and staff left the resident in bed for long periods. The investigation concluded these allegations were unsubstantiated.

An unannounced complaint investigation visit was conducted in response to allegations received on 2022-11-09 regarding staff mismanagement of resident medication and failure to report an incident as required.

The investigation substantiated that on a day in June 2022, memory care residents did not receive medications in the morning due to med techs calling out with COVID symptoms. However, the allegation that staff did not report an incident was found to be unfounded. Staffing plans were in place and utilized during the COVID outbreak.

The complaint alleging staff mismanaged resident medication was substantiated. The complaint alleging staff did not report an incident as required was unfounded.

An unannounced complaint investigation visit was conducted in response to allegations received on 2022-11-16 concerning staff abandonment of a resident, failure to meet needs while COVID positive, not following admission agreement, unauthorized photographing of a resident, and sharing confidential information.

The investigation found no preponderance of evidence to substantiate the allegations. The facility staff attempted to manage the resident's COVID isolation appropriately, followed admission agreement terms, and maintained confidentiality protocols. The allegations were determined to be unsubstantiated.

The complaint involved multiple allegations including staff abandonment of a resident during COVID isolation, failure to meet resident needs, breach of admission agreement, unauthorized photography, and sharing of confidential information. After review of documentation, interviews, and file examination, all allegations were found unsubstantiated.

The visit was conducted to deliver an immediate exclusion letter to exclude an employee of the facility.

An immediate exclusion letter was delivered and reviewed with the facility administrator. The report was discussed and a copy provided to the administrator.

The visit was an unannounced annual infection control inspection conducted to evaluate compliance with infection control practices and facility safety.

The facility was found to be clean, sanitary, and odorless with proper infection control practices observed, including entry procedures, daily monitoring logs, PPE supply, face coverings, containment strategies, staff training, and policies. No fire safety hazards or accessible bodies of water were observed, and chemicals and toxins were properly secured.

An unannounced complaint investigation visit was conducted in response to an allegation that the facility was providing inadequate food services to residents in care.

The investigation found that food is regularly provided to all residents, but one-on-one or hand-to-mouth feeding is not provided by staff in the memory care unit as outlined in the admission agreement. The allegation was determined to be unsubstantiated due to lack of evidence that the facility violated its policies.

The complaint alleged inadequate food services to residents. The investigation included interviews with staff and review of policies. It was found that one-on-one feeding is not provided by the facility but must be arranged by the resident's responsible party. The allegation was unsubstantiated.

The visit was an unannounced case management follow-up on an incident reported on June 23, 2022, involving a resident who was absent without official leave (AWOL).

The facility attempted to ensure basic services were met for the resident who eloped, including assigning a private caregiver and notifying all required parties. No citations were issued at this time.

The visit was triggered by a complaint regarding resident #1 being AWOL. The complaint was investigated and found that the facility took appropriate actions; no citations were issued.

An unannounced complaint investigation visit was conducted in response to allegations of inadequate staffing resulting in lack of care for residents and mismanagement of residents' medications.

The investigation found staffing to be adequate and no evidence of medication mismanagement. There were no incident reports or staff reports supporting the allegations. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included inadequate staffing and medication mismanagement, but no evidence was found to prove or disprove these claims.

The inspection was an unannounced complaint investigation visit triggered by allegations including the facility refusing to accept a resident back after hospitalization and failure to communicate with the resident's authorized representative.

The investigation substantiated that the facility illegally evicted a resident by not performing a required reappraisal and eviction procedures after readmission with new health needs. It also substantiated failure to notify the resident's responsible party of hospitalization due to inaccurate contact information. Another allegation regarding a resident sustaining a fracture while in care was unsubstantiated due to lack of evidence and uncooperative staff.

The complaint investigation was substantiated for allegations that the facility refused to accept a resident back after hospitalization without proper reappraisal and eviction procedures, and failed to notify the resident's authorized representative of the hospitalization. The allegation that the resident sustained a fracture while in care was unsubstantiated.

An unannounced case management visit was conducted to follow-up on a complaint investigation regarding allegations of a resident sustaining a fracture while in care, the facility refusing to accept the resident back, and failure to report/provide information to the resident's family.

The investigation found that a caregiver failed to cooperate with the investigation, the administrator failed to provide requested camera footage, and the facility illegally evicted a resident without proper reappraisal. The facility also failed to update the resident's emergency card and ensure sufficient staff to meet resident needs, resulting in citations under multiple California Code of Regulations sections.

Complaint #14-AS-20210913142555 involved allegations of a resident sustaining a fracture while in care, facility refusing to accept the resident back, and failure to report/provide information to the injured resident’s family. The complaint was substantiated with findings of illegal eviction, failure to cooperate with investigation, and failure to meet resident care requirements.

An unannounced plan of correction (POC) visit was conducted to verify and confirm that the facility complied with a citation issued on 2022-03-08 regarding failure to provide medical records to the responsible party as requested.

The facility failed to submit proof that the plan of correction was completed and did not provide the requested medical records to the responsible party, resulting in reissuance of the citation and assessment of civil penalties.

An unannounced complaint investigation visit was conducted in response to a complaint received on 2021-12-22 regarding the facility's failure to provide documentation related to injuries to the responsible party and an allegation of questionable death due to physical abuse.

The investigation substantiated that the facility failed to provide requested medical records and documentation promptly and appropriately, violating residents' personal rights. However, the allegation of questionable death caused by physical abuse was found to be unfounded based on medical records and death certificate review.

Complaint investigation was substantiated regarding failure to provide documentation related to injuries to the responsible party. The allegation of questionable death due to physical abuse was found to be unfounded.

The visit was an unannounced annual inspection conducted to evaluate compliance with licensing requirements and infection control practices.

The inspection found that COVID-19 signage was posted, infection control practices were reviewed, and most residents and all staff were observed wearing masks. The facility maintained appropriate storage of medications and toxins, sufficient food supplies, and adequate safety measures such as non-skid mats and first aid kits. Some recommendations were made to post hand-washing signs in shared bathrooms.

The inspection was an unannounced complaint investigation visit conducted in response to allegations that the facility was not meeting a resident's dietary needs and that staff were not providing supervision per doctor's orders.

The allegation regarding unmet dietary needs was unsubstantiated due to lack of sufficient evidence. However, the allegation that staff failed to provide supervision during meals as ordered by the resident's Nurse Practitioner was substantiated, resulting in a deficiency citation.

The complaint investigation was triggered by allegations received on 10/19/2021. One allegation regarding dietary needs was unsubstantiated. The other allegation regarding lack of supervision per doctor's orders was substantiated. Deficiencies were cited under California Code of Regulations, Title 22, Section 87611(e).

The inspection was conducted as an unannounced case management tele-inspection in response to a self-reported Unusual Incident Report dated March 26, 2021.

The Licensing Program Analyst interviewed the facility administrator and requested several documents related to the incident, including a staff written statement, employee handbook, resident's physician report, and police report. The resident involved was also asked to contact the analyst for confirmation.

The visit was triggered by a self-reported unusual incident. No substantiation status or findings of deficiencies were stated in the report.

An unannounced complaint investigation was conducted in response to allegations including lack of supervision resulting in a resident breaking their hip and multiple unexplained falls with injury while in care.

The investigation found the allegations of lack of supervision and multiple unexplained falls unsubstantiated due to sufficient staffing and lack of evidence. However, a separate allegation that tables in the facility posed a tripping hazard was substantiated based on evidence including surveillance video and staff interviews.

The complaint investigation was unannounced and initiated based on allegations received on 09/20/2019. The allegations included lack of supervision resulting in a resident breaking their hip and multiple unexplained falls with injury. These were found unsubstantiated. A separate allegation regarding tripping hazards from tables was substantiated.

The visit was a Case Management tele-visit conducted to provide Technical Assistance to the facility regarding COVID-19.

There were no active COVID-19 cases at the time of the visit. A staff member, private duty aide, and a resident had tested positive earlier in the month but all cases were resolved. The facility had contacted the local public health department for mass testing and was conducting contact tracing.

An announced case management continuation visit was conducted remotely to provide Technical Assistance to the facility regarding COVID-19 protocols and safety measures.

The facility's COVID-19 protocol and screening area were reviewed, and staff were interviewed and observed demonstrating proper hand washing technique. Two staff members had tested positive for COVID-19, and mass testing was conducted for all staff and residents with results pending. Recommendations were made to improve screening area placement and staff mask handling.

An announced case management visit was conducted remotely via video call to provide Technical Assistance regarding COVID-19 infection control, mitigation, and staffing plan.

The facility currently has two staff members who tested positive for COVID-19 and are isolating at home. The facility is coordinating with the Department of Public Health for mass testing scheduled on November 24 and 25, has conducted contact tracing and surveillance testing with negative results, and plans to continue weekly surveillance testing of 25% of staff after two rounds of negative tests.