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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601126
Report Date: 07/20/2023
Date Signed: 07/20/2023 12:55:01 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
07/14/2023 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230714123226
FACILITY NAME:PACIFICA SENIOR LIVING BURLINGAMEFACILITY NUMBER:
415601126
ADMINISTRATOR:BEAU AYERSFACILITY TYPE:
740
ADDRESS:250 MYRTLE ROADTELEPHONE:
(650) 343-2747
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:90CENSUS: 40DATE:
07/20/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Operations Specialist, Kathleen CalobeerTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff did not prevent resident from eloping
INVESTIGATION FINDINGS:
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On July 20, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with Operations Specialist, Kathleen Calobeer and explained the purpose of the visit.

Regarding the allegation that staff did not prevent resident from eloping, according to the reporting party, on July 12, 2023, Resident 1 (R1) left the facility unassisted. The reporting party indicated, that he/she called the facility to confirm that R1 had no restrictions to leaving the facility. According to the concierge, he/she confirmed R1 lives in assisted living and there are no restrictions in R1's file restricting him/her on leaving unassisted.

During the investigation, LPA reviewed R1's file and interviewed staff. Based on R1's file, R1 has a secondary diagnosis of dementia and is unable to leave the facility unassisted. According to staff interviewed, R1 leaves the facility after signing out and staff do not accompany or redirect him/her. In addition, it was indicated by staff interviewed that this has not been the first time R1 left the facility unassisted. Furthermore, based on observations, LPA observed a resident service plan binder on the front desk that indicate whether each resident is able to leave the facility unassisted or not. R1's service plan was observed to indicate R1 is unable to leave the facility unassisted.

Therefore, the allegation staff did not prevent resident from eloping is 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 is reviewed with Operations Specialist and a copy is provided with appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
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 2
Control Number 14-AS-20230714123226
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2023
Section Cited
CCR
87464(f)(1)
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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).

Violation of this regulation is not met as evidenced by:
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Facility will conduct an elopment in-service training with staff. All service plans on the front desk will be reviewed to ensure they are up to date. Facility will fax LPA a copy of list of residents who are able to leave the facility and not able to leave the facility unasissted which will be placed on the front desk at the facility.
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Based on interviews conducted and files reviewed, R1 has a secondary diagnosis of dementia and is unable to leave the facility unassisted, however on July 12, 2023, R1 left the facility unassisted. In addition, according to staff interviewed R1 has left the facility mulitple times in the past without a staff member accompanying R1. Furthermore, LPA observed R1's service plan in a resident service plan binder on the front desk to indicate R1 is not allowed to leave the facility unassisted.
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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.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2