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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601015
Report Date: 02/08/2021
Date Signed: 02/09/2021 08:17:40 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:TROUSDALE, THEFACILITY NUMBER:
415601015
ADMINISTRATOR:CHU, SYLVIAFACILITY TYPE:
740
ADDRESS:1600 TROUSDALE DRTELEPHONE:
(650) 443-3700
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:140CENSUS: 102DATE:
02/08/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Sylvia ChuTIME COMPLETED:
04:05 PM
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On this date, Licensing Program Analyst (LPA) Michael Garcia conducted a Case Management tele-visit to conduct a COVID-19 Technical Assistance to facility. Present on the call were Kathleen Weiss, RN, program clinical consultant and Sylvia Chu, administrator.

Facility's COVID-19 infection control and mitigation plan were reviewed. Facility's COVID-19 screening area, outdoor visitation area, and memory care unit were toured.

The Technical Assistance resulted with the following recommendations:
- Post proper donning sign outside the door and doffing sign inside the door of each COVID-19 positive resident rooms. (Signs provided.)
- Use N95 respirators when going inside a COVID-19 resident's room.

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

Report was reviewed and discussed with Administrator by end of visit.

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

DATE: 02/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2021
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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