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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601015
Report Date: 12/28/2021
Date Signed: 12/28/2021 05:42:17 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:TROUSDALE, THEFACILITY NUMBER:
415601015
ADMINISTRATOR:CHU, SYLVIAFACILITY TYPE:
740
ADDRESS:1600 TROUSDALE DRTELEPHONE:
(650) 443-3700
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:140CENSUS: 103DATE:
12/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sylvia ChuTIME COMPLETED:
06:00 PM
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LPA Audrey Jeung toured facility and grounds, consisting of private and shared one and two bedroom apartments--all with private bathrooms--on 5 floors; assisted living units on floors 2, 4, 5, 6, and secured memory care only on 3rd floor. Two stairwells on 3rd floor are equipped with a 15 second delayed egress: one is tested and operates as required. The elevator that accesses the 3rd floor is secured with a Wanderguard system; memory care residents wear Wanderguard pendants that emit an audible alert when they are in close proximity to elevator. The facility accommodates non-ambulatory and hospice residents. Rooms are equipped with emergency call systems, which can be activated from bathrooms and bedrooms. There is a large dining room, activity rooms, kitchen, medical clinic, beauty salon, fitness room, common areas, offices on the ground level.
Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Liquid soap and paper towels are available in public bathrooms. First-aid kit is inspected and complete. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Sylvia Chu is an RCFE administrator that oversees facility operations. Current RCFE administrator certificate is not available for review.

The following updated licensing forms or information are requested to be submitted to CCLD BY 1/11/22:

- Emergency Disaster Plan (LIC610E)
- Personnel Report (LIC500)
- Proof of current liability insurance

No deficiencies of the CA Code of REgulations, Title 22 are cited today. See LIC9102 for Technical Advisiory Notes related to COVID-19 protocols.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021
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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