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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601126
Report Date: 07/30/2024
Date Signed: 07/30/2024 10:51:17 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
05/22/2024 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240522112110
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:
07/30/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Operation Specialist, Kathleen CalobeerTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff are not according resident privacy while in care.
INVESTIGATION FINDINGS:
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On July 30, 2024, Licensing program Analyst (LPA), Murial Han conducted a visit to deliver the findings of the complaint investigation. LPA met with Operation Specialists, Kathleen Calobeer and Kathy Valencia and explained the purpose of today's visit.

Regarding to the allegation of- staff are not according resident privacy while in care, the reporting party stated that the facility notified resident #1 (R1)'s relatives with false and damaging information without R1' consent and destroyed R1's relationship with his/her relatives.

As part of the investigation, LPA interviewed the Resident Service Director and reviewed documents.

Based on the documents provided by the facility, it revealed that R1 does not have a diagnosis of Mild Cognitive Impairment and/or Dementia and R1 is able to communicate his/her needs. In addition, R1 signed the admission agreement upon admission.

LPA interviewed the Resident Service Director who stated that R1 is his/her own responsible party and acknowledged that the facility spoke to R1's relative about R1's Activities of Daily (ADLs) without R1's consent. The Resident Service Director stated the facility reached out to R1's relatives because they were hoping R1's relatives would convince R1 to participate in some of the ADLs that R1 was currently not.



Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
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 6
Control Number 14-AS-20240522112110
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PACIFICA SENIOR LIVING BURLINGAME
FACILITY NUMBER: 415601126
VISIT DATE: 07/30/2024
NARRATIVE
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After the investigation, this allegation is substantiated as the facility provided R1's personal information to R1's relatives without R1's permission which violated R1's Rights as the facility did not remain R1's information confidential.

Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, these allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed with the Operation Specialists, a copy is provided with Appeal Rights provided
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 14-AS-20240522112110
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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: 07/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2024
Section Cited
CCR
87468(a)(2)
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87468.2Additional Personal Rights of Residents(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities..2) To have their records and personal information remain confidential and to approve their release,...
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The administrator/licensee will develop a plan to ensure compliance and the plan will include staff education. A copy of the plan will be submitted to CCL by 8/7/2024.
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This requirement is not met as evidenced by based on record reviews and interviews, the facility shared R1's personal information with R1's relatives without R1's permission which poses a potential health risks to residents in care.
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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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
05/22/2024 and conducted by Evaluator Murial Han
COMPLAINT CONTROL NUMBER: 14-AS-20240522112110

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: DATE:
07/30/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Operation Specialist, Kathleen CalobeerTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff member handled resident in care in a rough manner.
Staff are bullying resident in care.
Staff are financially abusing resident in care.
Staff prevented resident in care from contacting the Long Term Ombudsman.
INVESTIGATION FINDINGS:
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On July 30, 2024, Licensing program Analyst (LPA), Murial Han conducted a visit to deliver the findings of the complaint investigation. LPA met with Operation Specialists, Kathleen Calobeer and Kathy Valencia and explained the purpose of today's visit.

Regarding to the allegation of- staff member handled resident in care in a rough manner, the reporting party stated that upon resident #1 (R1)'s admission, R1 was given a very abusive shower by a former staff member which left R1 with much pain after the shower.

As part of the investigation, LPA interviewed the Resident Service Director and R1.

The Resident Service Director denied the allegation and stated that the facility did not have any acknowledge of this incident, and R1 managed his/her own showers.

LPA interviewed R1 who stated the former staff did not intentionally hurt him/her and this person was not against R1. R1 stated that upon admssion, he/she was admitted with a medical device that was attached to his/her body part and while he/she was being wheeled into the shower room by the former staff, the medical device moved resulted pain in his/her body part.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 14-AS-20240522112110
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PACIFICA SENIOR LIVING BURLINGAME
FACILITY NUMBER: 415601126
VISIT DATE: 07/30/2024
NARRATIVE
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As part of the investigation, LPA interviewed the facility director who denied the allegation and stated that R1 was inquiring about where the Ombudsman's contact information was posted and it was provided to R1. The facility director did not know that R1 was asking for assistance with the call.

According to R1, staff did not prevent him/her from contacting the Ombudsman's office. R1 stated that the Resident Service Director provided the Ombudsman's contact information to R1 but R1 thought the Resident Service Director acted like he/she did not want to assist with the phone call, therefore, R1 traveled to the Ombudsman's office.

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

Based on records review, and interviews the department has determined that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED.

Report is discussed and reviewed with the Operation Specialists and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 14-AS-20240522112110
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PACIFICA SENIOR LIVING BURLINGAME
FACILITY NUMBER: 415601126
VISIT DATE: 07/30/2024
NARRATIVE
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After the investigation, this allegation is deemed to be unfounded as R1 stated that the medical device that was attached to his/her body part was causing the pain while he/she was being wheeled into the shower on a shower chair.

Regarding to the allegation of- staff are bullying resident in care, the reporting party stated that there was much bullying at the facility and no other details was provided.

As part of the investigation LPA interviewed the Administrator and the Resident Service Director who denied the allegation.

LPA interviewed R1 who denied the allegation and stated that there was a lady raised her finger while talking to R1 but this lady did not work at the facility.

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

Regarding to the allegation of - staff are financially abusing resident in care, the reporting party reported that the facility has attempted extortion of R1's funds, pushed current invoices under R1's door.

As part of investigation, LPA interviewed the Administrator who denied the allegation and stated that there were several conversations with R1 regarding to R1's outstanding balances and the facility has provided a copy of the invoices to R1 in person and placed it underneath R1's door.

LPA interviewed R1 who stated that the facility was not financially abusing his/her funds but they potentially could without any further details.

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

Regarding to the allegation of- staff prevented resident in care from contacting the Long Term Ombudsman, the reporting party stated that R1 asked one of the facility director's to make a call on behave of him/her to the Ombudsman office but the facility director did not comply so R1 went to the Ombudsman's office.

SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6