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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600184
Report Date: 03/24/2022
Date Signed: 03/24/2022 06:48:32 PM


Document Has Been Signed on 03/24/2022 06:48 PM - It Cannot Be Edited

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: 36DATE:
03/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Rowena Cancino and Amanda Dominguez NorthTIME COMPLETED:
07:00 PM
NARRATIVE
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During complaint investigation visit, LPA Jeung observed deficiencies of the CA Code of Regulations, Title 22. Citations appear on a following page.

Personnel Report (LIC500) is requested to be completed and submitted to CCLD BY 3/31/22.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
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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Document Has Been Signed on 03/24/2022 06:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: ATRIA BURLINGAME
FACILITY NUMBER: 415600184

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2022
Section Cited

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ADVERTISEMENTS & LICENSE NUMBER
In accordance with Health and Safety Code Sections 1569.68 and 1569.681, licensees shall reveal each facility license number in all public advertisements, including Internet, or correspondence.
This requirement is not met, as facility is doing business as, and advertising as "Pacifica
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Senior Living Burlingame," but without a valid RCFE license. Licensee has failed to operate consistent with licensure as ATRIA BURLINGAME, which poses a potential health, safety, or personal rights risk to clients in care.
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Type B
03/31/2022
Section Cited

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PERSONAL RIGHTS OF RESIDENTS
Residents in all RCFEs shall have the personal right to be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met, as COVID signage is almost absent in facility. There are no COVID reminder signs in lobby area, dining
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room, common rooms and halls and staff lounge to wear masks, maintain social distancing, cover nose and mouth when coughing or sneezing. Hand washing reminder sign is not posted in staff lounge. Licensee failed to ensure that relevant reminder signs are posted to promote a safe & healthy environment, which poses a potential health, safety, or personal rights risk to clients in care.
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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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/24/2022 06:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: ATRIA BURLINGAME
FACILITY NUMBER: 415600184

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2022
Section Cited

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TRANSFERABILITY OF LICENSE
The licensee shall notify the licensing agency and all residents receiving services, or their representatives, in writing as soon as possible and in all cases at least 30 days prior to the transfer of the property or business...as specified in Health and Safety Code Section 1569.191.
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This requirement was not met, as evidenced by absence of proof that written notice was issued to residents or their responsible parties. Licensee failed to ensure that proper notices were issued prior to doing business as Pacfica Senior Living, which poses a potential health, safety or personal rights risk to clients in care.
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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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3