<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601015
Report Date: 01/09/2024
Date Signed: 01/09/2024 06:26:54 PM

Document Has Been Signed on 01/09/2024 06:26 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, THEFACILITY NUMBER:
415601015
ADMINISTRATOR:CHU, SYLVIAFACILITY TYPE:
740
ADDRESS:1600 TROUSDALE DRTELEPHONE:
(650) 443-3700
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 140CENSUS: 125DATE:
01/09/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Sylvia ChuTIME COMPLETED:
01:40 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 January 9, 2024, Licensing Program Analysts (LPAs) Murial Han arrived unannounced to conduct an annual continuation for an annual required inspection that was conducted on December 27, 2023.

Upon arrival, LPA was greeted by the receptionist, Vivian Gonzales and LPA explained the purpose of the visit. Momentarily, LPA re-introduced myself to the Residential Living Advisor, Brienne Detar, Resident Care Coordinator, Joshua Lambengco and Business Office Manager, Aureliano Monteiro and explained the purpose of today's visit. The administrator arrived shortly thereafter and assisted with the rest of the inspection.

During today's visit, LPA was provided a tour by the Sales Coordinator, Maria Fe De Jesus and LPA toured the Assisted Living Units and observed temperatures in the resident's apartments and bathrooms to be adequate. The entire facility appeared to be cleaned and tidy.

In addition, LPA interviewed residents, facility staff and reviewed files.

LPA reviewed 4 resident records and all of them contained admission agreement, medical assessment- LIC 602 (Physician Order), Appraisal Needs and Service Plan, admission agreement, Resident Identification information, Pre-appraisal assessment, etc.
LPA reviewed 5 staff files and all of them contained personnel records, health screening, COVID-19 vaccination information, Job Description, Abuse Statement, First Aid/CPR, fingerprint/criminal background clearance. LPA observed 1 out of 5 staff files did not contain the initial staff training records and according to the director, it was not completed.

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 the administrator.

A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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 2
Document Has Been Signed on 01/09/2024 06:26 PM - It Cannot Be Edited


Created By: Murial Han On 01/09/2024 at 01:15 PM
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: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(1)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, the licensee did not comply with the section cited above in as staff #1 did not have the initial training records to proof that it was completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2024
Plan of Correction
1
2
3
4
The administrator/licensee will provide proof that the required training has been completed to CCL by 1/16/2024.
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
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2