415601126-4-12-2023-14-AS-KHOS-CR7J49-20230424064246

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601126
Report Date: 04/12/2023
Date Signed: 04/12/2023 12:33:11 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
03/23/2023 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230323131338

FACILITY NAME:	PACIFICA SENIOR LIVING BURLINGAME		FACILITY NUMBER:	415601126
ADMINISTRATOR:	NAIR, ANOOP		FACILITY TYPE:	740
ADDRESS:	250 MYRTLE ROAD		TELEPHONE:	(650) 343-2747
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY:	90	CENSUS: 46	DATE:	04/12/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Business Office Manager. Winnie Sato		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Residents left in soiled diapers
Facility wall in disrepair

INVESTIGATION FINDINGS:

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On April 12, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Business Office Manager, Winnie Sato and Resident Service Director, Rowena Cancino explained the purpose of the visit.

Regarding the allegation, residents are left in soiled diapers, there were no resident or staff name provided by the reporting party, however during the initial reporting, the reporting party indicated staff leave residents in soiled diapers and are not checking on them. During the investigation, LPA interviewed family members and staff. According to 4/4 of the interviewed staff and interviewed family members, it was indicated that there were days residents were observed being left in soiled diapers.

Regarding the allegation, facility wall in disrepair, according to the reporting party, there is a hole in the wall by the elevator on the 4th floor that "pours water" out and it has been like this for a year. During the investigation, LPA toured the facility and observed the 4th floor hallways. LPA observed a hole in the ceiling near the elevators on the 4th floor. According to the Regional Vice President of Operations, Beau Ayers, due to the winter storms, the ceiling was leaking water and eventually cracked. In addition, Beau stated that the Maintenance Director has purchased materials for the ceiling and the repair date is Monday 4/17/2023.

Based on observations and interviews conducted during this investigation, the preponderance of evidence standard has been met. Therefore, the allegation that facility wall in disrepair and the allegation that residents are left in soiled diapers is 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 is reviewed with Resident Service Director and a copy is provided with appeal rights.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
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.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20230323131338

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 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 HSC 1569.312	1 2 3 4 5 6 7	1569.312 Basic services requirements..Every facility required to be licensed under this chapter shall provide at least the following basic services: a) Care and supervision as defined in Section 1569.2. Violation of this regulation is evidenced by:	1 2 3 4 5 6 7	Licensee shall develop a plan of action in writing describing how the facility shall ensure residents are not being left in soiled diapers. Plan of correction to include plan to train staff.
	8 9 10 11 12 13 14	Based on interviews conducted, 4/4 staff members and family interviewed stated that there were days they observed residents being left in soiled diapers.	8 9 10 11 12 13 14	Copy of training to be submitted to LPA by 4/19/2023
Type B 04/19/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times... Violation of this regulation is evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator to submit a photo of the repaired ceiling to LPA by 4/19/2023. Licensee/Administrator to submit a copy of reciept of the purchased materials by 4/19/2023.
	8 9 10 11 12 13 14	Based on observations and interviews conducted, LPA observed a hole on the 4th floor ceiling wall on 3/27/23 and 4/12/23. According to the Regional Vice President of Operations, Beau Ayers, the Maintenance Director has purchased materials for the ceiling and the repair date is Monday 4/17/2023.	8 9 10 11 12 13 14

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	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
03/23/2023 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230323131338

FACILITY NAME:	PACIFICA SENIOR LIVING BURLINGAME		FACILITY NUMBER:	415601126
ADMINISTRATOR:	NAIR, ANOOP		FACILITY TYPE:	740
ADDRESS:	250 MYRTLE ROAD		TELEPHONE:	(650) 343-2747
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY:	90	CENSUS: 46	DATE:	04/12/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Business Office Manager. Winnie Sato		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

1
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5
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7
8
9

Staff do not treat residents with dignity

INVESTIGATION FINDINGS:

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5
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13

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
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.

LIC9099 (FAS) - (06/04)

Page: 3 of 3