Community Care Licensing

Document Has Been Signed on 01/23/2025 10:57 AM - It Cannot Be Edited

FACILITY NAME:	PACIFICA SENIOR LIVING BURLINGAME		FACILITY NUMBER:	415601126
ADMINISTRATOR/ DIRECTOR:	IGNACIO LOPEZ		FACILITY TYPE:	740
ADDRESS:	250 MYRTLE ROAD		TELEPHONE:	(650) 343-2747
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY: 90		CENSUS: 58	DATE:	01/15/2025
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Administrator, Ignacio Lopez		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

SUPERVISORS NAME: April Cowan LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025

Link to Parent Document Below:

FACILITY NAME: PACIFICA SENIOR LIVING BURLINGAME	FACILITY NUMBER: 415601126
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/15/2025

Type A

Section Cited

CCR

87355(e)(4)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility. 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 1 out of 5 staff was not associated with this facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2025
	Plan of Correction
1 2 3 4	The administrator associated the staff identified during the visit. However, the administrator/licensee still needs to develop a plan in writing to ensure compliance prior to staff working at the facility. The administrator/licensee will provide a copy of the plan to CCL by 1/16/2025.

Type A

Section Cited

HSC

1569.625(b)(2)

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 5 staff did not have training records indicating that their required annual training was completed in 2024 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2025
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure all required annual training is completed for facility staff and the plan shall indicate the date that the training will be completed for the 3 facility staff who were identified during the inspection. The administrator will provide a copy of the plan to CCL by 1/16/2025.

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025

Link to Parent Document Below:

FACILITY NAME: PACIFICA SENIOR LIVING BURLINGAME	FACILITY NUMBER: 415601126
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/15/2025

Type B

Section Cited

CCR

87355(j)

(j) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees in the individual's personnel file as required in Section 87412, Personnel Records. 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 4 out of 5 staff did not have the criminal record clearances in their personnel files which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/22/2025
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan in writing to ensure compliance and will provide a copy of the plan to CCL by 1/22/2025.

Section Cited

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

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025

Link to Parent Document Below:

FACILITY NAME: PACIFICA SENIOR LIVING BURLINGAME	FACILITY NUMBER: 415601126
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/15/2025

Type A

Section Cited

CCR

87411(f)

87411 Personnel Requirements - General This requirement is not met as evidenced by: Based on observation, interview, record reviews 3 out of 5 staff files did not have a copy of their TB and Health Screen results.
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 2 out of 5 staff files did not have a copy of their TB and Health Screen results which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2025
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure compliance and the plan shall indicate when the staff will complete their health screening process and TB. The administrator/licensee will submit a copy of the plan to CCL by 1/16/2025.

Section Cited

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

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025