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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600184
Report Date: 08/19/2022
Date Signed: 08/19/2022 05:21:31 PM


Document Has Been Signed on 08/19/2022 05:21 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:PACIFICA SENIOR LIVING BURLINGAMEFACILITY NUMBER:
415600184
ADMINISTRATOR:JEFF SUMABATFACILITY TYPE:
740
ADDRESS:250 MYRTLE RDTELEPHONE:
(650) 343-2747
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:90CENSUS: 34DATE:
08/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Anoop NairTIME COMPLETED:
05:30 PM
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LPA Jeung met with administrator to discuss Incident Report received 8/15/22 regarding incident of 8/6/22 regarding client #1. LPA reviewed client's file and observed resident sign out log. As per MD report and assessment, client is ambulatory and can independently leave facility unassisted.

No deficiency cited.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
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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