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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601126
Report Date: 10/21/2022
Date Signed: 10/21/2022 11:58:15 AM


Document Has Been Signed on 10/21/2022 11:58 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
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:
10/21/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Stephanie BriceTIME COMPLETED:
12:00 PM
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LPA Jeung followed up on initial pre-licensing inspections of 7/1/22 and 8/19/22. 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 in process. As per new administrator, all corrections referenced on previous visits have been made. Waste containers in kitchen are observed today with tight fitting lids. The following items were observed on 7/1/22 that needed to be addressed prior to licensure:

1. Emergency Disaster Plan (LIC610E) to be updated with location of fire extinguishers.
- Updated Emergency Disaster Plan was submitted to CCLD and includes 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 with covers
4. Laundry machine on 3rd floor is out of order
- 3rd floor laundry machine is operable
5. Visiting policy and admission agreement or notice of its availability must be posted
- Facility visitation policy and notice of availability of admission agreement are posted in common area
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

Component Three orientation is conducted. Ms. Brice acknowledged information contained in orientation and had no questions.

Immediate licensure is recommended, pending final review by Central Applications Unit.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2022
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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