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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600184
Report Date: 12/17/2020
Date Signed: 01/05/2021 10:46:08 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ATRIA BURLINGAMEFACILITY NUMBER:
415600184
ADMINISTRATOR:JEFF SUMABATFACILITY TYPE:
740
ADDRESS:250 MYRTLE RDTELEPHONE:
(650) 343-2747
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:90CENSUS: 34DATE:
12/17/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jeff SumabatTIME COMPLETED:
02:45 PM
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On this date, Licensing Program Analyst (LPA) Michael Garcia conducted a Case Management tele-visit to provide Technical Assistance (TA) to the facility regarding COVID-19. The tele-visit was conducted with Jeff Sumabat, executive director/administrator, with the assistance of Clarita D. Dela Cruz, RN, BSN of the California Department of Social Services.

The facility's COVID-19 protocol was discussed. Some parts of the facility were toured where staff and residents may congregate.

According to administrator, the facility currently has no COVID-19 cases. The last known positive case reported on December 2nd has been resolved. The facility has completed mass testing of its staff and residents on December 5th and December 12th. The facility is now conducting 25% surveillance testing of its staff every 7 days.

The TA visit resulted with the following recommendations:
- Screen staff for COVID-19 symptoms before and at the end of each shift.
- Ensure all trash cans have lids. Foot operated or touchless preferred.
- Post masking required while at the facility.
- Have staff who conducts COVID-19 screening at the main entrance wear face shields.
- Have laundry staff member to wear full PPEs when handling linens.

Administrator is to email LPA the facility's action plan regarding the above recommendations within 24 hours.

An electronic copy of the report was emailed to administrator for signature.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Michael GarciaTELEPHONE: (650) 380-4608
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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