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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415600184
Report Date:
10/21/2022
Date Signed:
10/21/2022 11:56:07 AM
Document Has Been Signed on
10/21/2022 11:56 AM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
PACIFICA SENIOR LIVING BURLINGAME
FACILITY NUMBER:
415600184
ADMINISTRATOR:
JEFF SUMABAT
FACILITY TYPE:
740
ADDRESS:
250 MYRTLE RD
TELEPHONE:
(650) 343-2747
CITY:
BURLINGAME
STATE:
CA
ZIP CODE:
94010
CAPACITY:
90
CENSUS:
34
DATE:
10/21/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
10:45 AM
MET WITH:
Stephanie Brice
TIME COMPLETED:
12:00 PM
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LPA Jeung met with new administrator for pre-licensing follow up inspection for change of ownership. See Facility Evaluation Report (LIC809) under license #415601126. The following items were pending from prior licensing visits with previous administrator:
1. Construction time-line/phases for ongoing facility improvements was requested on 8/19/22.
2. Copies of written notices to residents and family members regarding construction was requested on 8/19/22.
The above information is requested to be submitted to CCLD BY 10/28/22.
SUPERVISOR'S NAME:
Cara Smith
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Audrey Jeung
TELEPHONE:
(650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE:
10/21/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/21/2022
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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