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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600184
Report Date: 08/31/2021
Date Signed: 08/31/2021 10:57:25 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: 45DATE:
08/31/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Jeff SumabatTIME COMPLETED:
11:10 AM
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On August 31, 2021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management on-site visit to issue an immediate civil penalty after reviewing compliance for a deficiency cited on March 14, 2017.

On March 14, 2017, the facility was cited under California Code of Regulations, Title 22, Section 87465(a)(1) for failure to arrange medical treatment for Resident 1 (R1) after sustaining a broken arm due to a fall in the facility.

AN IMMEDIATE CIVIL PENALTY OF $150 WAS ASSESSED FOR VIOLATIONS THAT RESULTED IN SICKNESS OR INJURY TO A CLIENT IN CARE. THE ADMINISTRATOR WAS INFORMED THAT AN ADDITIONAL CIVIL PENALTY IS STILL BEING DETERMINED AND MIGHT BE ASSESSED BASED ON HEALTH AND SAFETY CODE ยง1569.49.

This report was reviewed and discussed with the Administrator, Jeff Sumabat at the end of the visit. A copy is provided to the Administrator..
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
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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