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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601126
Report Date: 11/15/2024
Date Signed: 11/15/2024 11:48:03 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
10/25/2024 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20241025150754
FACILITY NAME:PACIFICA SENIOR LIVING BURLINGAMEFACILITY NUMBER:
415601126
ADMINISTRATOR:IGNACIO LOPEZFACILITY TYPE:
740
ADDRESS:250 MYRTLE ROADTELEPHONE:
(650) 343-2747
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:90CENSUS: 63DATE:
11/15/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Ignacio LopezTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident wandered from the facility due to lack of staff supervision.
INVESTIGATION FINDINGS:
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On November 15, 2024, Licensing Program Analyst (LPA) Murial Han conducted a visit to deliver the investigation findings. LPA met with the administrator, Ignacio Lopez and explained the purpose of today's visit.

Regarding to the allegation of- resident wandered from the facility due to lack of staff supervision, the reporting party stated that resident #1 (R1)'s family received communication from the facility that R1 had been found outside of the facility and staff did not know how R1 got out of the memory care unit and they did not know how long R1 had been outside on the street.

As part of the investigation, LPA interviewed the Memory Care Director, Staff #1 (S1), and reviewed documents.

According to the Memory Care Director, on the day of the incident, it was during change of shift and the door alarm went off so they checked the doors and the doors were closed and no residents were around. They started searching room to room and discovered that R1 was not in the room. Subsequently, the Memory Care Director saw R1 in the courtyard in front of the facility and when staff went to escort R1 back to the facility, R1 was already on the sidewalk in front of the facility.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
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 5
Control Number 14-AS-20241025150754
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PACIFICA SENIOR LIVING BURLINGAME
FACILITY NUMBER: 415601126
VISIT DATE: 11/15/2024
NARRATIVE
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LPA interviewed staff #1 (S1) who stated that the door alarm went off and they responded to the alarm, however, they did not see R1 at the door. S1 also stated that they did not know R1 left the unit because the unit has 2 delayed egress doors and the elevator doors. Therefore, they did not know which exit R1 used to leave the unit.

Based on the Pre-placement Appraisal Information, the facility was aware that R1 has wandering behaviors as it was indicated on the Appraisal.

During the visit on 11/7/2024, LPA and the Resident Service Director tested the delayed egress doors and both doors were working properly and one of the doors lead to the courtyard in front of the facility where R1 was seen by the Memory Care Director.

After the investigation, this allegation is substantiated as R1 left a secured unit unattended and the facility did not know how R1 got out.

Based on interviews, observation, and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, these allegations were 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 was discussed with the Operation Specialists, a copy is provided with Appeal Rights provided
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
10/25/2024 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20241025150754

FACILITY NAME:PACIFICA SENIOR LIVING BURLINGAMEFACILITY NUMBER:
415601126
ADMINISTRATOR:IGNACIO LOPEZFACILITY TYPE:
740
ADDRESS:250 MYRTLE ROADTELEPHONE:
(650) 343-2747
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:90CENSUS: 62DATE:
11/15/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Ignacio LopezTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not safeguard resident's possessions while in care
INVESTIGATION FINDINGS:
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On November 15, 2024, Licensing Program Analyst (LPA) Murial Han conducted a visit to deliver the investigation findings. LPA met with the administrator, Ignacio Lopez and explained the purpose of today's visit.

Regarding to the allegation of staff did not safeguard resident's possessions while in care, the reporting party stated that the facility misplaced placed resident #1(R1)'s hearing aids and the facility have yet returned it to the responsible party.

As part of the investigation, LPA interviewed the facility director and reviewed documents.

According to the director, R1 did not have hearing aids upon admission. The director conducted a preplacement appraisal and noted on the preplacement apprasial that R1 has hearing impairment but not wearing hearing aids.

Based on the Preplacement Appraisal Information, the documentation indicated that R1 has auditory impairment and not wearing hearing aids.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 14-AS-20241025150754
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PACIFICA SENIOR LIVING BURLINGAME
FACILITY NUMBER: 415601126
VISIT DATE: 11/15/2024
NARRATIVE
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Based on the Needs and Services Plan, R1 did not have hearing aids.

Based on observation, interviews and records review, this allegations is deemed to be unsubstantiated.

Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

This report is review with the administrator and a copy is provided
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20241025150754
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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: 11/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2024
Section Cited
CCR
87705(b)(2)
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87705 Care of Persons with Dementia..(b) In addition to the requirements as specified in Section 87208, Plan of Operation,..(2) Safety measures to address behaviors such as wandering, aggressive behavior..
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The administrator/licensee will develop a plan to ensure residents will not leave the memory care unit unattended and the plan shall include staff training. The administrator/licensee will submit a copy of the plan to CCL by 11/18/2024.
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This requirement is not met as evidence by: based on interviews, observations and record reviews, R1 left the unit/facility unattended and was found by the courtyard in front of the facility and staff did not know how R1 got out which poses an immediate health and safety risks to residents 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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5