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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600990
Report Date: 10/31/2023
Date Signed: 10/31/2023 11:23:56 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
03/27/2023 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230327113531
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: 74DATE:
10/31/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Jeff SumabatTIME COMPLETED:
11:35 AM
ALLEGATION(S):
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-Staff did not respond to resident's call for assistance in a timely manner
-Staff did not provide a safe & secure environment for residents in care
INVESTIGATION FINDINGS:
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On October 31, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Jeff Sumabat and explained the purpose of the visit.

Regarding the allegation that staff did not respond to resident’s call for assistance in a timely manner, according to the reporting party, there was a lack of staffing at the facility and noticed that there was a delayed response when Resident 1 (R1) was calling for assistance.

During the investigation, LPA reviewed records and observed on 1/18/2023, R1 pressed the call pendant at 10:01AM requesting for assistance, however a staff member did not respond to R1’s call assistance request till 11:09AM. Based on record review, it took 67 minutes and 22 seconds to respond to R1’s call pendant.

Regarding the allegation, staff did not provide a safe and secure environment for residents in care, according to the reporting party, a stranger was in R1’s room for over an hour and when the issue was reported, staff was unconcerned. In addition, reporting party indicated R1 was bedridden at the time, and R1's room door was closed and at all times. (Continue to 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
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 6
Control Number 14-AS-20230327113531
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: SUNRISE OF BURLINGAME
FACILITY NUMBER: 415600990
VISIT DATE: 10/31/2023
NARRATIVE
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During the investigation, LPA interviewed staff and administrator at the time. According to the administrator at the time, there was a home health/PT provider that was observed in R1’s room, however this home health/PT provider was not providing R1 any services. In addition, according to administrator and interviewed staff, this home health provider has never provided services to R1. Furthermore based on staff interviews, R1 was bedridden and his/her room was always closed. The facility protocol at the time was if a visitor came in, they signed into the electronic system and front desk receptionist would radio staff to notify them that a visitor is visiting a specific resident and will open the resident's room door for the visitor. The facility failed to ensure safety and security for R1 as a home health provider who was not scheduled and assigned to work with R1 was observed in R1's room.

Therefore, the allegations that staff did not respond to resident's call for assistance in a timely manner and staff did not provide a safe & secure environment for residents in care is determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Administrator, Jeff Sumabat and a copy is provided with appeal rights.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
03/27/2023 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230327113531

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: DATE:
10/31/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Jeff SumabatTIME COMPLETED:
11:35 AM
ALLEGATION(S):
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-Staff did not ensure resident's oral hygiene needs were met
-Resident sustained a pressure injury due to staff neglect
-Staff did not ensure that resident was adequately fed
-Staff did not provide daily activities for resident
INVESTIGATION FINDINGS:
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On October 31, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Jeff Sumabat and explained the purpose of the visit.

Regarding the allegation staff did not ensure resident’s oral hygiene needs were met, according to the reporting party, due to the facility neglecting Resident 1 (R1), he/she developed an oral thrush.

During the investigation, LPA interviewed staff, and reviewed R1’s records. Based on record review, R1 was provided grooming services to maintain personal hygiene (combing hair, oral/dentures, shaving, applying lotion, etc.). Documents reviewed indicated that either R1 did not require help, or a staff member was assisting/stayed on standby.

According to the administrator at the time and interviewed staff, the facility tried to ensure that proper oral hygiene was provided to R1 however he/she did have a period of time where he/she was nauseous and refused to brush his/her teeth, but staff would assist R1 with gargling if refused.

Regarding the allegation resident sustained a pressure injury due to staff neglect, according to the reporting party, R1 developed an infectious and painful bed sore due to the neglect of the facility as R1 was not being turned. (Cont. to 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 14-AS-20230327113531
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: SUNRISE OF BURLINGAME
FACILITY NUMBER: 415600990
VISIT DATE: 10/31/2023
NARRATIVE
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During the investigation, LPA interviewed staff and reviewed R1’s file. According to the administrator at the time, R1 was admitted to the facility on 9/7/2022 and came from a skilled nursing facility with existing pain and discomfort in his/her lower extremities.

Based on documents reviewed, the facility was in frequent communication with R1’s physician and responsible party when they observed a change in R1’s condition. In addition, R1 had a home health nurse who would come examine and treat his/her wounds. According to interviewed staff, they denied this allegation and indicated that staff always attempted to reposition R1 and ensure he/she was comfortable, however R1 would refuse getting repositioned and refuse treatment. According to the administrator, R1’s wounds were an on-going issue since he/she was admitted to the facility, however the facility was working with the physician and home health to ensure R1 received the treatments he/she required.

Regarding the allegation staff did not ensure resident was adequately fed, according to the reporting party, R1 did not have a kitchen in his/her room and no staff checked in on R1 when he/she didn’t go to the dining room for meals, wasn’t ordering anything from the kitchen, or having food delivered from outside. In addition, according to the reporting party, in December of 2022, R1 had trouble eating and there was no communication with the family regarding R1’s dietary concern.

During the investigation, LPA interviewed staff and reviewed R1’s resident notes. According to staff interviewed, they denied this allegation and indicated that R1 complained about the facility food and stated he/she hated the food. Staff indicated that facility communicated with R1’s responsible party and notified R1’s physician regarding R1 refusing meals. According to the administrator at the time, R1 was always provided with alternative meal options if he/she did not like what was on the menu. In addition, the administrator indicated if R1 did not eat the facility’s meal, he/she would order food from outside the facility or R1’s family members would bring him/her food. Based on R1’s resident notes, R1 was provided meals by the facility however R1 would refuse to eat at times. According to the interviewed staff, if residents refuse to eat, staff will attempt to ask resident to eat at another time, provide alternative options, or provide fluids based on facility protocols. (Cont. to 9099C)
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 14-AS-20230327113531
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: SUNRISE OF BURLINGAME
FACILITY NUMBER: 415600990
VISIT DATE: 10/31/2023
NARRATIVE
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Regarding the allegation that staff did not provide daily activities for resident, according to the reporting party, after the facility had a Covid lock down in January, R1 never returned to her normal activities and stayed in his/her room.

During the investigation, LPA interviewed the administrator and interviewed staff. The administrator denied these allegations and indicated that during COVID activities were provided to both positive and negative residents. Based on 5/5 staff interviewed including the administrator, COVID negative residents were provided with small group activities while team members would check in with COVID positive residents and provide them with stimulating activities and brain games. In addition, the administrator indicated that during this time when staff offered activities to R1, he/she refused to join and preferred to stay in his/her room. The activities calendar was observed during the investigation. According to staff interviewed, although there was no activities director, team members were assigned to provide activities to residents throughout the day for both assisted living and memory care residents.

Therefore, based on the interviews conducted and information collected, the allegations above are UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Report is reviewed with Administrator, Jeff Sumabat and a copy is provided with appeal rights.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 14-AS-20230327113531
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: SUNRISE OF BURLINGAME
FACILITY NUMBER: 415600990
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2023
Section Cited
HSC
1569.312(a)
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§1569.312 Basic services requirements..Every facility required to be licensed under this chapter shall provide at least the following basic services:..(a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by:
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Licensee/administrator shall develop a plan in writing to ensure residents needs are met and call buttons are being responded to in a timely manner. This plan shall include staff training. POC shall be submitted by 11/1/2023.
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Based on record review, on 1/18/2023, R1 pressed the call pendant at 10:01AM requesting for assistance, however a staff member did not respond to R1’s call assistance request till 11:09AM. Based on record review, it took 67 minutes and 22 seconds to respond to R1’s call pendant which poses an immediate health and safety risk for residents in care
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Type B
11/07/2023
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
Violation of this regulation is not met as evidenced by:
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Licensee/Administrator shall develop a plan in writing to describe facility protocols regarding how facility will ensure visitors (home health, hospice agency, state agencies, family, etc) are visiting the correct resident/ going into the appropriate resident room
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Based on interviews conducted an information collected, a home health/PT aid was observed in R1's room, however was not scheduled or assigned to assist R1. Interviews indicated that the home health/PT aid was scheduled to see another resident that day.
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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6