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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601126
Report Date: 11/26/2024
Date Signed: 11/26/2024 02:27:05 PM

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
11/21/2024 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20241121125035
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: 65DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Resident Service Director, Rowena CancinoTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Staff did not ensure that residents are being transported to medical appointments.
INVESTIGATION FINDINGS:
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On November 26, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced 10-day complaint visit. LPA met with the resident service director, Rowena Cancino and explained the purpose of today's visit. LPA also spoke to the administrator over the phone.

Regarding to the allegation of- Staff did not ensure that residents are being transported to medical appointment, the reporting party stated that the facility van has been broken for eight weeks, residents are missing their appointments and the facility is not making transportation arrangements for the residents.

During today's visit, LPA interviewed the Resident Service Director, the Administrator, and residents.

The administrator stated that they have informed the residents verbally during the resident council meeting that the facility would be providing transportation via an Uber or a Taxi to and from their medical appointments while the facility van is being repair.

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

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
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 3
Control Number 14-AS-20241121125035
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: 11/26/2024
NARRATIVE
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The resident service director stated that the facility van has been broken for many weeks and the facility is offering to pay for the transportation while the van is being fixed.

LPA interviewed resident #1(R1) who stated that the administrator was going to make transportation arrangement for his/her recent medical appointment but the resident service director was not aware of it, and called R1's family member and the family member took R1 to the medical appointment.

LPA interviewed 2 other residents and they report that the van has been broken for more than eight weeks and they were not aware that the facility was providing other means of transportation such as an Uber or a Taxi. In addition, one of them stated that he/she had to cancel the medical appointments as he/she did not have any transportation arrangements. Furthermore, he/she stated that the residents were not scheduling any appointments as there was no transportation arrangements.

After the investigation, this allegation is deemed to be substantiated as the residents reported that they were missing their appointments and they were not scheduling new appointments as there was no other means of transportation that was provided by the facility. In addition, they were not aware that the facility was offering Uber/ Taxi rides.

Based on interviews, and observations 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 administrator; a copy is provided with Appeal Rights provided
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 14-AS-20241121125035
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: 11/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/02/2025
Section Cited
CCR
87465(a)(2)
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87465 Incidental Medical and Dental Care..(a) A plan for incidental medical and dental care shall be developed by each facility...(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation..
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The administrator will provide a plan of correction in writing of what is the facility's plan to ensure that the residents are aware of the alternative transportation that the facility is offering while the van is being repaired.
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This requirement is not met as evidenced by based on interviews and observations, residents are missing their appointments and not scheduling new appointments as the facility van is broken and they were not aware of the other means of transportation which poses a potential health risks to residents in care.
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In addition, the plan shall include the estimated time for the van to be fixed. The administrator will provide a copy of the plan to CCL by 1/2/2025.
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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: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3