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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600184
Report Date: 06/16/2022
Date Signed: 06/16/2022 10:40:39 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/10/2022 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220610105855
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: 35DATE:
06/16/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Executive Director, Anoop NairTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Resident eloped from facility.
INVESTIGATION FINDINGS:
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On June 16, 2022, Licensing Program Analyst (LPA) Komal Charitra, conducted an unannounced 10-day complaint visit. LPA met with Executive Director, Anoop Nair. LPA explained the purpose of the visit. LPA was not screened at entry point.

Regarding the allegation that resident eloped from the facility, according to the complainant, resident (R1) has dementia and left the facility without being properly watched. During the visit, LPA reviewed R1's file and interviewed staff. According to the file reviewed and the documentation collected, it indicates that R1 has a diagnosis of Dementia and is unable to leave the facility unassisted.

According to the Executive Director, R1 was newly admitted to the facility and was placed on 2 hour status checks. On June 8, 2022, staff observed R1 sitting in the lobby area about 10 minutes before elopment. R1 was missing for approximately an hour and thity minutes before returning back to the facility with the police.

Based on the file reviewed and interviews conducted, a resident did elope from the facility, therefore the preponderance of evidence standard has been met; therefore, this allegation is Substantiated.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 9099D. Failure to correct the deficiencies may result in civil penalties.

Report reviewed with the Executive Director, and a copy is provided with the appeals rights is provided.






Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 14-AS-20220610105855
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2022
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services(f)- Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).

Violation of this regulation is not met as evidenced by:
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The Executive Director and/or designee will provide caregiver training regarding supervision to prevent this from happening again and will submit a copy of the lesson plan and the sign-in sheet to CCL by 6/17/22.
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Based on the file reviewed and interviewed conducted, the facility did not ensure basic services were being met, due to lack of supervision R1 AWOL. In addition, R1 is unable to leave the facility unassisted, which poses an immediate health, safety and personal rights risk to residents.
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One on one care was provided to resident; Facility spoke to the family and had a care conference regarding moving resident to memory care. Resident was moved memory care unit on 6/15/22.
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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) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2