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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601126
Report Date: 10/03/2023
Date Signed: 10/03/2023 11:42:14 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/26/2023 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230926104552
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: 48DATE:
10/03/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Resident Service Director, Rowena Cancino; Glenda BertucciTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility staff do not ensure resident records are properly maintained
INVESTIGATION FINDINGS:
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On October 3, 2023 Licensing Program Analyst (LPA) Murial Han and LPA John Calandra conducted a 10-day complaint visit. LPAs met with Resident Service Director, Rowena Cancino and explained the purpose of the visit. Administrator, Glenda Bertucci arrived shortly thereafter and assisted with the rest of the visit.

Regarding to allegation of - facility staff do not ensure resident records are properly maintained, reported party stated that there were missing documents in resident #1 (R1)'s file such as admission application. In addition, reporting party stated that he/she was asked by staff to complete some paper work that was supposed to be completed by the physician.

As part of the investigation, LPAs reviewed R1 and 3 other resident's clinical and financial files, and interviewed resident service director.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 14-AS-20230926104552
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 10/03/2023
NARRATIVE
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In R1's medical file, LPAs observed including but not limiting LIC 602, pre- placement appraisal, needs and services plan, resident functional needs assessment, admission agreement, etc. In addition, LPAs observed an incomplete LIC 602 in the medical file and according to the resident service director, facility is working with R1's responsible party to obtain an updated LIC 602.

LPAs reviewed 3 other resident's file and observed LIC 602 (physician's order), pre-placement appraisal, needs and services plan, resident functional needs assessment, admission agreement, etc.

After the investigation, this allegation is deemed to be unfounded.

Based on the above information, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis.

Report was discussed and a copy of this report is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2