415601126-1-30-2024-14-AS-MHAN-CZYSLR-20240130125847

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415601126
Report Date: 01/30/2024
Date Signed: 01/30/2024 05:42:52 PM

Document Has Been Signed on 01/30/2024 05:42 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 BURLINGAME		FACILITY NUMBER:	415601126
ADMINISTRATOR:	GLENDA BERTCCUI		FACILITY TYPE:	740
ADDRESS:	250 MYRTLE ROAD		TELEPHONE:	(650) 343-2747
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY:	90	CENSUS: 48	DATE:	01/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Resident Service Director, Rowena Cancino		TIME COMPLETED:	01:10 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 January 30, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with resident service director, Rowena and explained the purpose of the visit. The administrator arrived shortly thereafter and assisted with the inspection. LPA toured facility and grounds of this 4-story facility. There are two elevators and 3 stairwells, and 69 apartments--small studios, large studios, and one bedroom units, all have a private bathroom. On the ground floor, there are offices, kitchen, living and main dining rooms. The second floor is the memory care unit, and can only be accessed by a keypad for the elevator. There is a dining room, kitchen, and common rooms on the 2nd floor. There are laundry rooms on the 2nd, 3rd and 4th floors. There is an underground parking garage. LPA observed an emergency call system installed in each bathroom and all assisted living clients have pendants that transmit audible and visual signal to the centrally monitoring system and pagers carried by care staff and med techs. LPA observed fire extinguishers were last serviced on 2/1/2023 and water temperatures were measured at 105 - 116 degrees F. LPA observed medications are secured in medication rooms on 1st and 2nd floors and toxins are secured in locked maintenance rooms on 2nd, 3rd and 4th floors. LPA reviewed documentation for emergency drills.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PACIFICA SENIOR LIVING BURLINGAME	FACILITY NUMBER: 415601126
	VISIT DATE: 01/30/2024

NARRATIVE

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During the kitchen tour, LPA observed perishable and non-perishable foods are adequate. The walk-in refrigerator and freezer floors were dirty, the mental shelves in the walk-in refrigerator was observed to have black partials hanging on the metal bars, the metal tray to hold clean cups was dirty, etc.

LPA reviewed 5 resident records and all of them contained admission agreement, medical assessment- LIC 602 (Physician Order), Appraisal Needs and Service Plan, Resident Identification information, Pre-appraisal assessment, etc.

LPA reviewed 3 staff files and all of them contained personnel records, health screening, COVID-19 vaccination information, Job Description, Abuse Statement, fingerprint cleared and associated to the facility and First Aid/CPR documentation was not adequate.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/30/2024 05:42 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: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 3 out of 4 staff members did not have a valid CPR/First Aid Certificate which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2024
	Plan of Correction
1 2 3 4	The administrator will provide a plan to ensure compliance and the plan shall indicate the date that staff members would complete their CPR/First Aid training. In addition, the administrator will provide a copy of S1, S2, and S4's renewed CPR/First Aid certificates. The administrator will provide a copy of the plan to CCL by 1/31/2024

Type A

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as several areas in the kitchen was observed to be dirty which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2024
	Plan of Correction
1 2 3 4	The administrator will develop a plan to ensure compliance and the plan needs to indicate when the kitchen will be cleaned and how is it going to be maintained. The administrator will provide a copy of the plan to CCL by 1/31/2024 and submit photos to proof that the identified areas are cleaned.

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 Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 01/30/2024 05:42 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: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as facility was not able to provide proof that drills were conducted accordingly which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2024
	Plan of Correction
1 2 3 4	The administrator will develop a plan to ensure compliance and submit a copy of the plan to CCL by 1/31/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

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