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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601126
Report Date: 07/14/2023
Date Signed: 07/14/2023 10:01:12 AM


Document Has Been Signed on 07/14/2023 10:01 AM - 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: 69DATE:
07/14/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sales Director, Kristal RobinsonTIME COMPLETED:
10:15 AM
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On July 14, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced plan of correction visit to follow up on visits made on 6/29/23 and 7/10/23. LPA met with Sales Director, Kristal Robinson and explained the purpose of the visit.

On 7/10/23, LPA conducted a plan of correction visit to ensure facility is in compliance with citations that were issued on 6/29/2023. During this visit, LPA assessed civil penalties for facility failing to provide 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 was assessed from 7/7/2023 through 7/10/2023.

On 7/10/2023, LPA received the plan of correction from the facility for CCR 87211. Deficiency is now verified and citation is now cleared. Civil penalties will be stopped on 7/10/2023.

LPA reviewed report with Sales Director and a copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2023
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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