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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601126
Report Date: 06/06/2023
Date Signed: 06/06/2023 11:59:05 AM


Document Has Been Signed on 06/06/2023 11:59 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: 40DATE:
06/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Regional Vice President of Operation, Beau AyersTIME COMPLETED:
12:10 PM
NARRATIVE
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On June 6, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on a death report that was submitted to CCLD on May 11, 2023. LPA met with Regional Vice President of Operation, Beau Ayers, Operations Specialist, Kathleen Calobeer, and Resident Care Director, Rowena Cancino and explained the purpose of the visit.

The Licensee reported on May 10, 2023, Resident 1 (R1) passed away and the immediate cause of death is not disclosed. LPA requested a copy of the death certificate, however the facility was unable to provide one. The Licensee indicated that Business Office Manager, W. Sato went check on R1 after receiving a call indicating R1 needs assistance. R1 was found in his/her room unresponsive with no pulse noted.

During the visit today, LPA reviewed R1's file, interviewed staff and requested for a copy of R1's death certificate. According to facility, the death certificate has still not been obtained.

Based on file reviewed, R1 had a diagnosis of chronic pain syndrome, major depressive disorder, anxiety disorder, with mild cognitive impairment. In addition, according to the physician's report from 7/2021, R1 did not exhibit symptoms of aggressive, inappropriate, and sundowning behavior. Based on resident assessment from 5/4/2023, R1 did not require any assistance with ADLs from the facility. According to staff interviewed, R1 did have a change in condition, and starting showing signs of aggression, inappropriate behavior, and signs of dementia, however no re-assessment was done. In addition, although resident care notes were being updated, the Licensee failed to develop an individualized needs and service plan for R1 to address change in condition.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with Administrator; a copy of the report is provided with appeal rights.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/06/2023 11:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2023
Section Cited
CCR
87463(a)

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87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to...

Violation of this regulation is not met as evidenced by:
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Licensee to submit a written plan to address how facility will document and update a residents needs and service plan if the resident shows a change in condition.
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Based on file reviewed and interviews conducted, the facility failed to reassess R1 after showing new behaviors that were not addressed in current care plan and appraisal. In addition, the Licensee failed to develop an individualized needs and service plan for R1 to address change in condition.
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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.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023
LIC809 (FAS) - (06/04)
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