415601015-12-27-2023-14-AS-MHAN-CYWTYM-20231227140859

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415601015
Report Date: 12/27/2023
Date Signed: 12/27/2023 06:45:31 PM

Document Has Been Signed on 12/27/2023 06:45 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	TROUSDALE, THE		FACILITY NUMBER:	415601015
ADMINISTRATOR:	CHU, SYLVIA		FACILITY TYPE:	740
ADDRESS:	1600 TROUSDALE DR		TELEPHONE:	(650) 443-3700
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY:	140	CENSUS: 125	DATE:	12/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Administrator, Sylvia Chu		TIME COMPLETED:	02:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/27/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with the administrator and explained the purpose of today's visit. Administrator provided a tour of the common area with a large dining room, activity rooms, kitchen, medical clinic, beauty salon, fitness room and kitchen. Facility directors provide a tour of the memory care unit that consists of private and shared one and two bedroom apartments, dining room, activity rooms, etc. The memory care unit is located on the 3rd floor and during tour, LPA observed the delayed egress doors by the two stairwells are working properly and the entrance to the unit is secured with a wanderguard system door. The memory care residents wear a wanderguard device/pendent that emit an audible alert when they are in close proximity of the door to prevent residents from wandering off the unit. During testing of the wanderguard door, resident #1 (R1)'s wanderguard device/pendent did not emit an audible and according to staff, the battery for the device needed to be changed. Medications are locked in the medication room and inaccessible to residents in care. Lighting is sufficient for comfort. Chemicals, toxins, and sharps objects in the memory care kitchen/dinning room were observed to be unlocked and accessible to residents.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

Document Has Been Signed on 12/27/2023 06:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: TROUSDALE, THE	FACILITY NUMBER: 415601015
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above as the toxins, chemicals and sharp were unlocked in the Memory Care unit which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/28/2023
	Plan of Correction
1 2 3 4	The administrator/licensee will provided a plan to ensure compliance and the plan shall include staff training. The administrator/licensee will provide a copy of the plan and in-service record to CCL by 12/28/2023.

Type A

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above as expired food items were observed in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/28/2023
	Plan of Correction
1 2 3 4	The administrator/licensee will provided a plan to ensure compliance and the plan shall include staff training. The administrator/licensee will provide a copy of the plan to CCL by 12/28/2023.

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 Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 12/27/2023 06:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: TROUSDALE, THE	FACILITY NUMBER: 415601015
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87468.1(a)(2)

This requirement is not met as evidenced by: resident #(1) wanderguard device/pendent did not go off by the front entrance of the memory care unit.
	Deficient Practice Statement
1 2 3 4	Based on interview, observation and record review the licensee did not comply with the section cited above as R1's wanderguard device did not go off by the front entrance of the memory unit which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/28/2023
	Plan of Correction
1 2 3 4	The administrator/licensee will check all the resident's wanderguard device to ensure they are working properly and provide a signed and dated statement to CCL of completion. In addition, the administrator/licensee will develop a plan of the process to ensure resident's wanderguards are checked properly. The administrator/licensee will provide a copy of the statement and plan to CCL by 12/28/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: TROUSDALE, THE	FACILITY NUMBER: 415601015
	VISIT DATE: 12/27/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

During tour of the kitchen, LPA observed 2 days of perishables and 7 days of nonperishable foods for the residents. LPA observed expired food items in the walk-in refrigerator.

Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher was last serviced on 7/13/2023.

Hot water temperature is measured at 105- 111 degrees F.

LPA is not able to complete the entire inspection today and will return on another day to complete the inspection.

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

This report is reviewed and discussed with memory care director. A copy of this report and the appeal rights were provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4