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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601126
Report Date: 07/10/2023
Date Signed: 07/10/2023 03:12:43 PM


Document Has Been Signed on 07/10/2023 03:12 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:PACIFICA SENIOR LIVING BURLINGAMEFACILITY NUMBER:
415601126
ADMINISTRATOR:BEAU AYERSFACILITY TYPE:
740
ADDRESS:250 MYRTLE ROADTELEPHONE:
(650) 343-2747
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:90CENSUS: DATE:
07/10/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Executive Director, Emaude (Alex) TayebiTIME COMPLETED:
03:25 PM
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On July 10, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced plan of correction (POC) visit to verify and confirm that the facility is in compliance with the citations that were issued on 6/29/2023. LPA met with Executive Director, Emaude (Alex) Tayebi and explained the purpose of the visit.

On 6/29/2023, LPA cited the facility California Code of Regulations (CCR) Title 22, 87355 Criminal Record Clearance, 87412 Personnel Records, 87211 Reporting Requirements, 87463 Reappraisals, and 87506 Resident Records. The Executive Director was able to associate the staff members who were observed to not be associated on 6/29/2023 in LPAs presence.

During the visit today, the Executive Director was unable to provide LPA with the plan of correction for CCR 87211 Reporting Requirements. Due to the citation not being corrected by 7/6/2023, a civil penalty in the amount of $400.00 is being assessed ($100/day) from 7/7/2023 through 7/10/2023 and will continue to accrue until corrected.

In addition during the visit, the Executive Director was able to provide LPA with the plan of correction for CCR 87463 Reappraisals, 87506 Resident Records, and 87412 Personnel Records. Deficiencies are now verified as corrected and cleared.

Report is reviewed with Executive Director and a copy is provided with civil penalty.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
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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