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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601126
Report Date: 04/04/2024
Date Signed: 04/04/2024 12:52:58 PM


Document Has Been Signed on 04/04/2024 12:52 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:GLENDA BERTCCUIFACILITY TYPE:
740
ADDRESS:250 MYRTLE ROADTELEPHONE:
(650) 343-2747
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:90CENSUS: 55DATE:
04/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Glenda BertccuiTIME COMPLETED:
01:05 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 April 4, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to follow-up on an incident that was report to CCL by the facility. LPA met with Resident Service Director, Rowena Cancino and Administrator, Glenda Bertccui. LPA explained the purpose of today's visit.

On March 28, 2024, facility reported that facility received a call from the post office reporting that one of the residents was there. Subsequently, facility director went to the post office to pick up the resident(R1). However, someone had already called 911 and resident was transferred to the hospital for further evaluation.

During today's visit, LPA interviewed the Resident Service Director and the Administrator who stated that R1 usually gets transported by the facility van when R1 wanted to leave the facility; 2 days prior to the incident, R1 was informed by facility staff that the van would be out of service and if R1 could hold off on conducting outings.

During the day of the incident, R1 was persistent with leaving the facility to conduct some personal business. As R1 was signing out at the front desk, the receptionist reminded R1 that R1 was not to leave the facility unassisted. However R1 left by him/herself without further actions performed by facility to ensure R1's safety.

Based on R1's Physician's Order (LIC 602), R1 was not able to leave the facility unassisted. Therefore, deficient is cited under California Code of Regulations, Title 22 as the facility did not ensure care and supervisor was provided while R1 was out of the facility.

Civil penalty of $250 will be assessed today for repeat violation as this deficiency was cited on 7/20/2023.

Deficiencies of the 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 the administrator; a copy is provided with the appeal rights.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
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 04/04/2024 12:52 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: 04/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2024
Section Cited
CCR
87464(f)(1)

1
2
3
4
5
6
7
87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

1
2
3
4
5
6
7
The administrator will develop a plan to ensure compliance and the plan shall include the facility's protocols to prevent this incident from happening again. The plan shall include staff training.
8
9
10
11
12
13
14
This requirement is not met as evidenced by R1 left the facility unassisted despite R1's LIC 602 indicated that R1 was not to leave the facility unassisted which posed an immediate health risks to residents in care.
8
9
10
11
12
13
14
The administrator will submit a copy of the signed and dated plan to CCL by 4/5/2024 indicating when the training will be completed.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2