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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601015
Report Date: 01/14/2025
Date Signed: 01/14/2025 03:09:40 PM

Document Has Been Signed on 01/14/2025 03:09 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:TROUSDALE, THEFACILITY NUMBER:
415601015
ADMINISTRATOR/
DIRECTOR:		CHU, SYLVIAFACILITY TYPE:
740
ADDRESS:1600 TROUSDALE DRTELEPHONE:
(650) 443-3700
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 140CENSUS: 105DATE:
01/14/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Memory Care Director, Anne AquinoTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
NARRATIVE
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On January 14, 2025, Licensing Program Analysts (LPA) Murial Han conducted an unannounced case management visit to deliver the findings in reference to complaint # 14-AS-20241127162037. LPA met with Memory Care Director and LPA explained the purpose of the visit.

During the investigation, the reporting party stated that on 11/11/2024, resident #1 (R1) communicated to the responsible party that he/she was not feeling well and the responsible party requested the facility staff to check resident #1 (R1)'s vitals and to report back. However, no one call the responsible party back and he/she was unsure if anyone did the vitals.

LPA interviewed the memory care director who acknowledged that the staff did not do the vitals and did not call R1's responsible party back.

Based on the complaint investigation, the facility did not take R1's vitals as requested by R1's responsible party.

Deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed and discussed with memory care director.

A copy of this report and the Appeal Rights is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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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Document Has Been Signed on 01/14/2025 03:09 PM - It Cannot Be Edited


Created By: Murial Han On 01/14/2025 at 10:18 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: TROUSDALE, THE
FACILITY NUMBER: 415601015

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/15/2025
Section Cited
CCR
87464(f)(1)

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87464 Basic Services(f) Basic services shall at a minimum include:(1) Care and supervision, this requirement is not met as evidenced by based on interview and record review, the facility did not check R1's
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The administrator/licensee will develop a plan in writing to prevent this from happening again and the plan shall include staff training and the topics that will be covered during the training.
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vitals ask requested by R1's responsible party after R1 expressed not feeling well poses an immediate health risk to residents in care.
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The administrator/licensee will provide a copy of the plan to CCL by 1/15/2025.

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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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
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