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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601126
Report Date: 07/01/2022
Date Signed: 07/05/2022 09:44:39 AM


Document Has Been Signed on 07/05/2022 09:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:PACIFICA SENIOR LIVING BURLINGAMEFACILITY NUMBER:
415601126
ADMINISTRATOR:NAIR, ANOOPFACILITY TYPE:
740
ADDRESS:250 MYRTLE ROADTELEPHONE:
(650) 343-2747
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:90CENSUS: 31DATE:
07/01/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Muli KaulaveTIME COMPLETED:
07:30 PM
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Applicant Pacifica SL California LLC, Pacifica Burlingame LP and Pacifica Senior Living Mgmt LLC, represented by facility administrator Anoop Nair, has applied for RCFE licensure for 90 non ambulatory elderly persons. Fire clearance has been approved. Facility is currently operated as Atria Burlingame #415600184.
LPA Jeung 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 living room is currently being renovated, so it is not accessible. 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. Facility sketch accurately reflects floor plan. Medications are secured in medication rooms on 1st and 2nd floors and toxins are secured in locked maintenance rooms on 2nd and 3rd floors. Food preparation and service items are present, as well as perishable and non-perishable food. There is an emergency call system installed in each bathroom and all assisted living clients have pendants that transmit audible and visual signal to monitor in sales office and pagers carried by care staff and med techs.
In addition, Emergency Disaster Plan must be updated and location of fire extinguishers must be added.
Cage #4 in garage to be identified by signage.

LPA observed that door of memory care room occupied by COVID resident is wide open, not identified as isolation room, and another resident walked into open door. THis was discussed with Mr. Nair.

Due to time constraints, a follow up visit will be necessary. See SIX Advisory Notes for additional observations. Component Three orientation to be conducted at follow up visit.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022
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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