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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600990
Report Date: 04/16/2021
Date Signed: 04/16/2021 05:27:40 PM

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:SUNRISE OF BURLINGAMEFACILITY NUMBER:
415600990
ADMINISTRATOR:ABBIE APOLINARIOFACILITY TYPE:
740
ADDRESS:1818 TROUSDALE DRTELEPHONE:
(650) 692-2805
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:97CENSUS: 63DATE:
04/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Abbie ApolinarioTIME COMPLETED:
03:00 PM
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On April 16, 2021, at approximately 1:30pm, Licensing Program Analyst (LPA) Michael Garcia conducted an unannounced case management inspection in response to an unusual incident that the facility had self-reported. Due to COVID-19 pandemic, the inspection was conducted remotely, via video call, with Abbie Apolinario, executive director/administrator.

Today, LPA interviewed the administrator and reviewed some documents.

Administrator shall ensure to email the following documents to LPA within 24 hours of this report:
- Current resident roster.
- Resident 1 (R1)'s Physician's Report.
- Nurses' notes regarding R1 for the past 7 days.
- Staff 1 (S1)'s written statement dated April 15, 2021.
- S1's April work schedule.
- S1's most current training records regarding resident rights.

An electronic copy of the report was emailed to Abbie for signature.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Michael GarciaTELEPHONE: (650) 380-4608
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021
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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