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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601126
Report Date: 03/24/2022
Date Signed: 03/24/2022 06:53:46 PM

Document Has Been Signed on 03/24/2022 06:53 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PACIFICA SENIOR LIVING BURLINGAMEFACILITY NUMBER:
415601126
ADMINISTRATOR:SUMABAT, JEFFFACILITY TYPE:
740
ADDRESS:250 MYRTLE ROADTELEPHONE:
(650) 343-2747
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 90CENSUS: 36DATE:
03/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Rowena Cancino and Amanda Dominguez NorthTIME COMPLETED:
07:00 PM
NARRATIVE
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During complaint investigation to this facility, licensed as Atria Burlingame #415600184, LPA Jeung observed deficiency of the California Code of Regulations, Title 22, which is cited on a following page.

RCFE licensure has not yet been approved nor granted, yet Pacifica Senior Living Burlingame has been doing business as, and advertising itself as a licensed RCFE.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
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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Document Has Been Signed on 03/24/2022 06:53 PM - It Cannot Be Edited


Created By: Audrey Jeung On 03/24/2022 at 11:52 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2022
Section Cited
CCR
87206(a)

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ADVERTISEMENTS & LICENSE NUMBER
In accordance with Health and Safety Code Sections 1569.68 and 1569.681, licensees shall reveal each facility license number in all public advertisements, including Internet, or correspondence.
This requirement is not met, as facility is doing business as, and advertising as "Pacifica
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Plan of correction to cease operating as Pacific Senior Living Burlingame to be submitted to CCLD BY DUE DATE
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Senior Living Burlingame," but without a valid RCFE license. Applicant has failed to operate consistent with licensure as ATRIA BURLINGAME, which poses a potential health, safety, or personal rights risk to clients 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:Julio Montes
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022


LIC809 (FAS) - (06/04)
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