415600184-9-1-2022-14-AS-KHOS-CHZKD6-20220906074810

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600184
Report Date: 09/01/2022
Date Signed: 09/01/2022 09:53:16 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
08/11/2022 and conducted by Evaluator Komal Charitra

COMPLAINT CONTROL NUMBER: 14-AS-20220811100755

FACILITY NAME:	PACIFICA SENIOR LIVING BURLINGAME		FACILITY NUMBER:	415600184
ADMINISTRATOR:	JEFF SUMABAT		FACILITY TYPE:	740
ADDRESS:	250 MYRTLE RD		TELEPHONE:	(650) 343-2747
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY:	90	CENSUS: 32	DATE:	09/01/2022
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Regional Director of Operation, Amanda North		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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-Staff are not wearing masks
-Staff are not enforcing visitors to wear masks

INVESTIGATION FINDINGS:

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On September 1, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Regional Director of Operations, Amanda North, and explained the purpose of the visit.

Regarding the allegation that staff are not wearing masks, according to the complainant, he/she has observed staff not wearing masks in the facility. In addition, the complainant indicated that there were times he/she entered the facility and observed the front desk receptionist and the med-techs either not wearing a mask or not properly wearing a mask. During the investigation, LPAs visited the facility 3 times: 8/19/2022, 8/29/2022, and 9/1/2022. On 8/29/2022, LPA observed a staff member (S1) coming out of the elevator without a mask on. Based on interviews conducted, S1 is the Maintenance Director and has had previous complaints in the past from visitors for not wearing a mask in the facility. In addition, interviewed staff acknowledged that S1 has a pattern of not wearing a mask and has been given S1 several verbal warnings and multiple write-ups for not wearing a mask.

Based on observations and interviews conducted, it was determined staff are not wearing masks. Therefore the preponderance of evidence standard has been met; therefore, this allegation is Substantiated.

CONT. to 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20220811100755

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 BURLINGAME	FACILITY NUMBER: 415600184
	VISIT DATE: 09/01/2022

NARRATIVE

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Regarding the allegation that staff are not enforcing visitors to wear masks, according to the complainant, the facility is undergoing construction and the construction workers were observed to not have a face mask on. During the investigation, LPAs visited the facility 3 times: 8/19/2022, 8/29/2022, and 9/1/2022. Although LPA observed construction workers wearing a mask during all three investigation visits, interviewed staff acknowledged that some construction workers did not wear a face mask while working inside the facility until this issue was brought up to Executive Director. In addition, interviewed staff indicated, on 8/12/2022, the Executive Director spoke to the construction workers regarding wearing a mask at all times when working inside the facility and corrected the issue. Since 8/12/2022, all construction workers have been complying to the facility's masking requirements.

Based on observations and interviews conducted, it was determined staff are not enforcing visitors to wear masks. Therefore the preponderance of evidence standard has been met; therefore, this allegation is Substantiated.

87468.1(a)(2)- Personal Rights of Residents in All Facilities- This is the second repeat violation within 12 months. Facility was cited on 3/24/2022 under section 87468.1(a)(2).

$1,000 CIVIL PENALTY ASSESSED FOR REPEAT VIOLATION WITHIN 12 MONTHS.

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 is reviewed with the Regional Director of Operations, Amanda North, and a copy is provided with appeals rights. In addition, Civil penalty is provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20220811100755

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 BURLINGAME	FACILITY NUMBER: 415600184
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/01/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/08/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	PERSONAL RIGHTS OF RESIDENTS: Residents in all RCFEs shall have the personal right to be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Violation of this regulation is not met as evidence by:	1 2 3 4 5 6 7	Facility corrected deficiency on 8/12/2022, by providing in-service training to staff regarding masking. In addition on 8/12/22, the Executive Director spoke to the construction workers regarding wearing a mask inside the facility. Facility will provide LPA a copy of staff attendance for the in-service training conducted on 8/12/2022.
	8 9 10 11 12 13 14	Based on observations and interviews conducted, facility failed to ensure all facility staff are wearing a face covering inside the facility. In addition, facility failed to ensure that all visitors are wearing a face mask prior to entering the facility.	8 9 10 11 12 13 14	A civil penalty of $1,000 is issued on 9/1/2022, for a repeat violation within 12 months.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

LIC9099 (FAS) - (06/04)

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