415600184-1-23-2023-14-AS-CSMH-CQKVYF-20230404165102

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600184
Report Date: 01/23/2023
Date Signed: 01/23/2023 05:03:30 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/16/2022 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220316155209

FACILITY NAME:	ATRIA 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: 42	DATE:	01/23/2023
		UNANNOUNCED	TIME BEGAN:	04:20 PM
MET WITH:	Stephanie Brice		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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- Visitors are not screened for COVID upon entry
- Facility is not secure
- Facility phones are not being answered

INVESTIGATION FINDINGS:

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Based on investigation conducted by this Department, which included witness interviews, the above allegations are determined to be substantiated.

In February 2022 and on at least 3 days in March 2022, visitors were not screened upon entry, as no one was at the reception desk. Visitors were not screened for COVID and entered the facility unknown to staff. In February and March 2022, at least 2 persons called facility, but no one answered the phone.

These allegations are substantiated, as the preponderance of evidence standard has been met.

Deficiencies of the California Code of Regulations, Title 22 are cited on a following page.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20220316155209

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ATRIA BURLINGAME	FACILITY NUMBER: 415600184
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/03/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	PERSONAL RIGHTS OF RESIDENTS Residents in all RCFEs shall have the personal right to be accorded safe, healthful, comfortable accommodations, furnishings,equipment. This requirement was not met, as visitor protocols were not in place, which included COVID screening and general sign-in procedures.	1 2 3 4 5 6 7	Administrator to ensure that visitors sign in and records shall include at least visitors' contact numbers. Proof of correction to be sent to CCLD BY DUE DATE
	8 9 10 11 12 13 14	In the absence of reception desk staff, visitors accessed the facility without signing in and were not COVID screened. Licensee failed to ensure that general and COVID safety protocols were maintained, which posed a potential health, safety or personal rights risk to clients in care.	8 9 10 11 12 13 14
Type B 02/03/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	PERSONNEL REQUIREMENTS - GEN'L Facility personnel shall at all times be sufficient in numbers, & competent to provide the services necessary to meet resident needs. In facilities licensed for 16 or more, sufficient support staff shall be employed... Additional staff shall be employed as necessary to perform office work...This requirement was not met due	1 2 3 4 5 6 7	Administrator to develop, implement and submit plan of correction to CCLD by DUE DATE
	8 9 10 11 12 13 14	to high staff turnover, as evidenced when incoming calls to facility by at least 2 persons were unanswered & reception desk staff were absent when visitors arrived on multiple occasions. Licensee failed to ensure that sufficient support staff were employed following management transition, which posed a potential health, safety or personal rights risk to clients.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/16/2022 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220316155209

FACILITY NAME:	ATRIA 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: 42	DATE:	01/23/2023
		UNANNOUNCED	TIME BEGAN:	04:20 PM
MET WITH:	Stephanie Brice		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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- Resident sustained an unwitnessed fall resulting in multiple fractures
- Medical attention was not sought for resident in a timely manner

INVESTIGATION FINDINGS:

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These allegations have been investigated by the Community Care Licensing Division of the CA Department of Social Services, and determined to be unfounded. Investigation included records review and interviews.

Former client had multiple unwitnessed falls due to declining health condition. After each fall incident, staff notified client's responsible party immediately, and sought medical attention as needed. This was documented appropriately.

These unfounded allegations could not have happened and/or are without a reasonable basis.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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