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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600184
Report Date: 07/08/2021
Date Signed: 07/08/2021 04:30:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
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: 40DATE:
07/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jeff SumabatTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted an annual inspection today and met with Executive Director Jeff Sumabat.

At 11:30 AM, LPA entered the facility through the facility's central entry point and was screened by staff. At 12:15 PM, a tour of the facility was conducted. The assisted living and memory care floors were inspected. COVID-19 postings were observed. Staff were observed wearing face coverings. Residents were observed having lunch in the communal dining room. Memory care residents were observed engaged in puzzle and coloring activities with staff.

The facility has at least 30 days' supply of personal protective equipment (PPE) including face shields, isolation gowns, gloves, and face masks. Hand sanitizers, soap, and paper supplies were observed available.

According to Administrator, the facility has achieved over 80% vaccination rate against COVID-19 for both residents and staff. The facility is currently accepting visitors inside the facility.

Revisions are requested on the facility's COVID-19 mitigation plan. Licensee shall submit revised plan and current proof of control of property to CCLD by July 16, 2021.

No deficiencies were cited. Exit interview conducted with Administrator and a copy of this report was provided during visit.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
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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