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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600184
Report Date: 02/18/2021
Date Signed: 02/19/2021 12:36:01 PM

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: 35DATE:
02/18/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Jeff SumabatTIME COMPLETED:
04:55 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 with the assistance from Irene Thibault, RN, MBA of the California Department of Public Health. The TA visit was conducted with Jeff Sumabat, executive director/administrator.

The facility's COVID-19 mitigation protocol was discussed. Some common areas of the facility were toured including the screening area, dining, front porch/visitation area, 2nd floor memory care unit, shared restroom, and staff break room.

The TA visit resulted with the following recommendations:
- Ensure a proper handwashing sign is posted in front of every washing station/sink, including the staff break room.
- Ensure the facility's COVID-19 mitigation plan, LIC808, is updated and submit revision within 48 hours, if needed.

Administrator shall ensure to submit a signed and dated action plan regarding the above recommendations and email the action plan to LPA within 24 hours.

Report reviewed and discussed with Jeff at the end of the visit.

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

DATE: 02/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2021
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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