415601126-4-28-2023-14-AS-KHOS-CRFK7V-20230502073946

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601126
Report Date: 04/28/2023
Date Signed: 04/28/2023 11:32:21 AM

Unsubstantiated

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
04/21/2023 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230421133732

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: 44	DATE:	04/28/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Business Office Manager, Winnie Sato		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Staff do not serve nutritious foods
Staff do not treat residents with dignity
Facility in disrepair
Facility has pests

INVESTIGATION FINDINGS:

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On April 28, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with the Business Office Manager, Winnie Sato and explained the pupose of the visit.

Regarding the allegation the staff do not serve nutritous foods, according to the reporting party, the facility food is not nutritous and caused Resident 1 (R1) diarrhea. During the investigation, LPA interviewed kitchen staff, Regional Vice President of Operations, Beau Ayers, observed facility's weekly menu and reviewed R1's file. Based on R1's file, he/she is on a regular diet (not therapeutic diet). According to Beau and interviewed kitchen staff, there has not been any complaints of residents getting sick from the facility food. In addition kitchen staff indicated that they provide residents with meals that fit their dietary needs which is updated as needed by Food Services Director, Christina Mejia Dominguez.

During the visit today, LPA observed facility cook making bacon and cheese melt with sweet potato fries which matched the weekly menu provided to residents. In addition, according to the cook, if residents don't want what's on the menu, the facility cook makes alternative meals. Today's alternative meal for lunch is a sandwich bar. (continue to 9099C)

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: 04/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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-20230421133732

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
	VISIT DATE: 04/28/2023

NARRATIVE

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Regarding the allegation staff do not treat residents with dignity, according to the reporting party, R1 wanted to address his/her concerns with the Regional Vice President of Operations, Beau Ayers however he dismissed R1 from his office.

On 4/12/2023, LPA Charitra concluded a complaint investigation (complaint control: 14-AS-20230323131338) for the same allegation of “staff do not treats residents with dignity.” According to 5/5 family members interviewed and 3/3 staff members interviews, it was indicated that they have never observed staff to be rude or roughly handle residents in care. Based on the information gathered, this allegation was unsubstantiated.

Regarding the allegation that the facility is in disrepair, according to the reporting party, R1’s bedroom toilet has not been working and the facility has not repaired it. In addition, the reporting party indicated that room 304 has a broken window.

During the investigation, LPA toured the facility, observed room 304 and R1’s bedroom toilet, and observed the maintenance orders from April. Based on observations, LPA observed room 304 window to be in good repair and working condition. According to the resident that resides in room 304, he/she has never had any issues with the window. LPA observed R1’s room toilet to be in good repair and working condition. In addition, LPA reviewed the maintenance log and did not observe any orders for a bathroom toilet repair for R1.

Regarding the allegation that facility has pests, according to the reporting party, it was observed that there are insects, scorpions, and wasps in the facility, and rats in the garage.

During the investigation, LPA interviewed the Regional Vice President of Operations, Beau Ayers, who denied this allegation and indicated that there has not been any reports of insects, pests, or rodents in or around the community. In addition, Beau indicated that the facility has a contract with Ecolab to come and inspect the community inside and outside monthly. LPA reviewed the latest reports from Ecolab dated March 20, 2023 and April 17, 2023, which states that there were no pests or cockroach activity found. Furthermore, during the facility tour LPA did not observe any rats, insects or scorpions.

Therefore, based on the interviews conducted and information collected, the allegations above are UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Report is reviewed with Business Office Manager, Winnie Sato and a copy is provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC9099 (FAS) - (06/04)

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