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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601126
Report Date: 12/30/2024
Date Signed: 12/30/2024 04:14:28 PM

Document Has Been Signed on 12/30/2024 04:14 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PACIFICA SENIOR LIVING BURLINGAMEFACILITY NUMBER:
415601126
ADMINISTRATOR/
DIRECTOR:		IGNACIO LOPEZFACILITY TYPE:
740
ADDRESS:250 MYRTLE ROADTELEPHONE:
(650) 343-2747
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 90CENSUS: 58DATE:
12/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Ignacio LopezTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On January 30, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with the administrator, Ignacio Lopez and explained the purpose of today's visit.

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, and all of the room have a private bathroom. On the ground floor, there are resident rooms, 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 elevators and the unit has 30 second egress exit doors. In addition, there is a dining room, a small kitchen, and common rooms on the 2nd floor. There is a laundry rooms on the 2nd, 3rd and 4th floors.

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 3/26/2024 and water temperatures were measured at 105 - 109 degrees F through-out the facility.

LPA observed medications, sharps, and chemicals are locked and inaccessible to residents in care.

A review of (4) staff files was conducted and noted on the LIC 859

LPA will return on another day to complete the inspection.

This report is review and discussed with the administrator.

A copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
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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