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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601015
Report Date: 12/03/2024
Date Signed: 12/04/2024 03:35:22 PM

Document Has Been Signed on 12/04/2024 03:35 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: 140TOTAL ENROLLED CHILDREN: 0CENSUS: 87DATE:
12/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator, Sylvia ChuTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
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On December 3, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. Upon entry, LPA met with Business Office Manager, Arno Manteiro and Memory Care Director, Anne Aquino and LPA explained the purpose of today's visit. The administrator arrived shortly thereafter.

Memory Care Director provided a tour of the common area with a large dining room, activity rooms, kitchen, medication rooms, resident rooms, laundry rooms, etc.

The memory care unit is located on the 3rd floor and all the residents wear a wander guard device/pendent that emit an audible alert when they are in close proximity of the door to prevent residents from wandering off the unit.

Medications are locked in the medication/work rooms on the 2nd, 3rd, 4th and 5th floor and inaccessible to residents in care. Lighting is sufficient for comfort.

Chemicals, toxins, and sharps objects were observed to be unlocked and inaccessible to residents.

2 days of perishables and 7 days of nonperishable foods were observed for the residents.

Fire extinguishers throughout the facility were last serviced on 7/31/2024. Fire drill records observed to be sufficient.

Hot water temperature in the resident's bathrooms and kitchen were measured at 105- 111 degrees F.
April CowanTELEPHONE: (650) 266-8889
Murial HanTELEPHONE: (619) 209-9761
DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: TROUSDALE, THE
FACILITY NUMBER: 415601015
VISIT DATE: 12/03/2024
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A review of (5) resident files was conducted and noted on the LIC 858.
A review of (5) staff files was conducted and noted on the LIC 859.

The following updated forms/information are requested to be submitted to CCLD BY 12/6/2024:
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan (signed and dated)
• Proof of current Liability Insurance
- Administrator Certification

No deficiencies cited today.

This report is reviewed and discussed with the memory care director and the administrator.

A copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC809 (FAS) - (06/04)
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