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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601126
Report Date: 07/20/2023
Date Signed: 07/20/2023 01:03:04 PM


Document Has Been Signed on 07/20/2023 01:03 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: 40DATE:
07/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Operations Specialists, Kathleen CalobeerTIME COMPLETED:
01:15 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 July 20, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit in relation to complaint investigation (complaint number: 14-AS-20230714123226). LPA met with Operation Specialist, Kathleen Calobeer and explained the purpose of the visit.

During the complaint investigation visit, LPA found that the facility failed to submit the incident report for the incident that occurred on July 12, 2023 where Resident 1 (R1) signed out and left the facility unassisted. According to the Resident Care Coordinator, Rowena Cancino, it was acknowledged an incident report was not submitted to CCL.

87211 Reporting Requirements- A civil penalty of $250 is assessed on 7/20/2023 for a repeat violation within 12 months. This violation was cited on 6/29/2023.

During the visit, LPA observed Staff 1 (S1) to not be fingerprint cleared. Based on personnel record review with facility, LPA observed S1 to not be fingerprint cleared and association status to be pending. Operations specialists immediately notified S1 and S1 left the facility during LPAs visit and will not return until fingerprints are cleared.

This violation results in a civil penalty of $100 per day x 1 day = $100

Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in additional civil penalties.

Report is reviewed with Operations Specialist and a copy is provided with civil penalties and appeal rights.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
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 2


Document Has Been Signed on 07/20/2023 01:03 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: PACIFICA SENIOR LIVING BURLINGAME
FACILITY NUMBER: 415601126

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2023
Section Cited
CCR
87211(a)(1)

1
2
3
4
5
6
7
87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...

Violation of this regulation is not met as evidenced by:
1
2
3
4
5
6
7
Facility will conduct an in-service training with Resident Care Director and Memory Care Director regarding reporting requirements.
8
9
10
11
12
13
14
Based on record review and interviews conducted, facility acknowledged to not submitted CCL a incident report for an incident that occurred on July 12, 2023.
8
9
10
11
12
13
14
A civil penalty of $250 is assessed for repeat violation
Type A
07/21/2023
Section Cited
CCR87355(e)(1)

1
2
3
4
5
6
7
87355 Criminal Record Clearance: (e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or..

Violation of this regulation is not met as evidenced by:
1
2
3
4
5
6
7
S1 was immediately sent home during LPAs visit. Licensee will ensure fingerprints and associations are up to date.
8
9
10
11
12
13
14
Based on observations and record review, LPA observed S1 to not be fingerprint cleared.
8
9
10
11
12
13
14
A civil penalty of $100 is being assessed.
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 SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2