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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600990
Report Date: 04/27/2021
Date Signed: 04/30/2021 08:24:40 AM

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:
04/27/2021
TYPE OF VISIT:Case Management - COVID-19ANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Abbie ApolinarioTIME COMPLETED:
10:50 AM
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On April 27, 2021, Licensing Program Analyst (LPA) Michael Garcia conducted a case management tele-visit to provide COVID-19 Technical Assistance to the facility with the assistance of Mira Belle Villamin, BSN, PHN, RN of the California Department of Public Health. The tele-visit was conducted with Abbie Apolinario, executive director/administrator.

According to administrator, a facility staff tested positive for COVID-19 in the last 14-days and is isolating at home. The facility has conducted their first round of COVID-19 mass testing of staff and residents on April 20 - April 22. All test results were negative. Second round of mass testing is on April 28 - April 29.

The facility's COVID-19 infection control and mitigation plan were reviewed.
The facility's physical plant was toured, including the outdoor visitation area.

The Technical Assistance resulted with the following recommendations:
- Post COVID-19 signage by the entrance door (mask wearing requirement, etc).
- Inside visitation areas need to have social distancing signs or have the extra chairs removed to encourage social distancing.
- Arrange furniture at the outdoor visitation areas to reflect social distancing or post social distancing signs.
- Memory care dining area: remove extra chairs to reflect social distancing


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SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Michael GarciaTELEPHONE: (650) 380-4608
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021
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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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: SUNRISE OF BURLINGAME
FACILITY NUMBER: 415600990
VISIT DATE: 04/27/2021
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- Activity room: furniture arrangement does not reflect social distancing but is currently open only for 1 staff and 1 resident at a time. Most activities are done outside but during inclement weather and activity room becomes essential in residents’ daily living, need to ensure that social distancing is promoted and reflected in the arrangement of furniture, signs, etc.
- Ensure all trash cans have lids. Foot operated preferred.
- Post capacity/social distancing signage on the elevator doors.
- Ensure each handwashing stations have proper handwashing sign.

Administrator shall ensure to email a dated and signed written action plan to LPA within 24 hours regarding the above recommendations.

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: 04/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2021
LIC809 (FAS) - (06/04)
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