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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601126
Report Date: 08/19/2022
Date Signed: 08/19/2022 05:17:08 PM


Document Has Been Signed on 08/19/2022 05:17 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: 34DATE:
08/19/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Anoop NairTIME COMPLETED:
05:30 PM
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LPA Jeung followed up on initial pre-licensing inspection of 7/1/22, as no information has been received from administrator. Since 7/1/22, name change has been made official, and facility is operating as Pacifica Senior Living Burlingame; facility is being managed by Pacifica Senior Living and change of ownership is being processed. On 7/1/22, the following items were observed that needed to be addressed prior to licensure:

1. Emergency Disaster Plan (LIC610E) to be updated with location of fire extinguishers
2. Cage #4 in garage will be identified by signage
- Cage #4 in garage is identified as such with a sign
3. Waste containers in kitchen are observed without tight fitting lids (per Section 87303 Maintenance and Operation)
- Waste containers in kitchen are observed today without covers
4. Laundry machine on 3rd floor is out of order
- 3rd floor laundry machine is operable
5. Visiting policy must be posted
- Due to painting of walls in first floor common areas, there are currently no postings
- Visitor policy is given to LPA today, and will be posted when common area walls are dry
6. There must always be an administrator designee on-site.
- In-service training on chain of command was provided to staff on 7/14/22
- Copy of sign-in sheet is provided to LPA

Mr. Nair to notify LPA Jeung to confirm that items #1 and #3 are addressed. A follow up visit and Component Three orientation to be conducted.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022
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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