<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601126
Report Date: 04/12/2023
Date Signed: 04/12/2023 12:34:08 PM

Document Has Been Signed on 04/12/2023 12:34 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
SF COASTAL AC/SC, 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: 46DATE:
04/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Business Office Manager, Winnie SatoTIME COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On April 12, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on a death report submitted on April 6, 2023. LPA met with Business Office Manager, Winnie Sato and Resident Service Director (RSD) Rowena Cancino and explained the purpose of the visit.

The Licensee reported on March 21, 2023, Resident 1 (R1) passed away and that the immediate cause od death was not disclosed. Based on the death report that was submitted to CCL, the private caregiver notified the Resident Services Director that R1 was choking from his/her phlegm and when the Resident Services Director arrived to R1's room, R1 was not responding. During the visit today, LPA reviewed R1's file and requested copies of documents. Based on file reviewed, R1 is an Assisted Living resident who has no prior history of choking or swallowing. LPA to follow up on this incident after reviewing documents collected and facility to request a copy of death certificate.

In addition, during the visit today, LPA found that the facility failed to report as required. According to CCR 87211 Reporting Requirements, the licensee shall send a written report to the licensing agency and the person responsible for the resident when a resident dies, regardless of cause or where death occurred, within seven days of the death. It was observed in R1's death report that R1 passed away on March 21, 2023, however the death report was not submitted to CCL till April 6, 2023.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Resident Service Director and a copy is provided with appeal right
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/12/2023 12:34 PM - It Cannot Be Edited


Created By: Komal Charitra On 04/12/2023 at 09:49 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: 04/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2023
Section Cited
CCR
87211(a)(1)(A)

1
2
3
4
5
6
7
87211 Reporting Requirements:
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted to the licensing agency...for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...(A) Death of any resident from any cause regardless of where the death occurred...

Violation of this regulation is evidenced by:
1
2
3
4
5
6
7
Facility Administrator to read and review CCR 87211 and submit acknowledgment to LPA by 4/19/2023.
8
9
10
11
12
13
14
Based on record review, the Licensee/Administrator failed to report a death of a resident within 7 days of occurrence. It was observed on the death report submitted that R1 passed away on 3/21/23, however the death report was not submitted to CCL until 4/6/23.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Cara Smith
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2