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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601126
Report Date: 06/29/2023
Date Signed: 06/29/2023 12:20:49 PM


Document Has Been Signed on 06/29/2023 12:20 PM - 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: 69DATE:
06/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director, Emaude (Alex) TayebiTIME COMPLETED:
12:34 PM
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On June 29, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that occurred on June 7, 2023. LPA met with Executive Director, Emaude (Alex) Tayebi and explained the purpose of the visit.

The Licensee reported Resident 1 (R1) had an unwitnessed fall in his/her room. R1 was transported to the hospital and head injuries were noted.

During the visit, LPA reviewed R1's file and interviewed the Administrator and Resident Services Director, Rowena Cancino. According to staff interviewed, R1 has had a total of three falls the past month (5/1/2023, 5/23/2023, and 6/7/2023). During record review, LPA discovered that incident reports for the incidents that occurred on 5/1/2023 and 5/23/2023 were not reported to CCLD.

According to file reviewed, R1 has a diagnosis of Alzheimer's Dementia with behavioral disturbances. Based on R1's service plan, R1 is fall risk and has a wandering behavior. The service plan was dated 5/3/2023 after R1 had an unwitnessed fall and was taken to the hospital on 5/1/2023. R1 had two additional falls after the service plan was updated, however the facility failed to reassess R1 after the falls that occurred on 5/23/2023 and 6/7/2023. In addition, during record review, LPA observed the service plan to be incomplete as it was not be signed by R1's responsible party.

During the record review, LPA observed Staff 1 (S1) and S2 to not be associated at the facility. LPA reviewed facility personnel records and observed S1 and S2 to have fingerprint clearance, however was not associated to the facility.

Continue to 809C.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
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 5


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
VISIT DATE: 06/29/2023
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LPA did not observed S1's and S2's criminal record clearance documentation in personnel files. Executive Director was able to provide LPA with proof from Guardian indicating staff are fingerprint cleared but not associated to the facility.

A civil penalty of $200 is being assessed for S1 and S2 for not being associated to the facility.

87463(a) Reappraisal- A civil penalty of $250 is assessed on 6/29/2023 for a repeat violation within 12 months. This violation was cited on 6/6/2023.

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 Executive Director; a copy of the report is provided with appeal rights. Copy of civil penalty is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 06/29/2023 12:20 PM - 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: 06/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2023
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)..

Violation of this regulation is not met as evidenced by:
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Facility will submit LIC9182 to LPA with a copy of S1's and S2's clearance letter and DL by 6/30/2023 OR facility will use Guardian to associate both employees to the facility.
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Based on record review, LPA observed S1 and S2 to have fingerprint clearance, however was not associated to the facility.
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A civil penalty of $200 is being assessed for S1 and S2 for not being associated
Type B
07/06/2023
Section Cited
CCR87211(a)(1)

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87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...

Violation of this regulation is not met as evidenced by:
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Licensee/Administrator to conduct an in-service training regarding reporting requirements. Administrator to submit a sign-in sheet of training to LPA by 7/6/2023.
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Based on record review, the Licensee failed to submit two incident reports from 5/1/2023 and 5/23/2023 to CCLD.
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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: 06/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 06/29/2023 12:20 PM - 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: 06/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/06/2023
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/Administrator to submit a written plan to address how facility will ensure that any change of condition is documented and residents are reassessed after having reoccurring incidents.
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Based on file reviewed, the Licensee reassessed R1 after having an unwitnessed fall incident on 5/1/2023, however the facility failed to reassess R1 after having two additional unwitnessed falls on 5/23/2023 and 6/7/2023.
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A civil penalty of $250 is assessed on 6/29/2023 for a repeat violation within 12 months. This violation was cited on 6/6/2023.
Type B
07/06/2023
Section Cited
CCR87506(a)

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87506 Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility...

Violation of this regulation is not met as evidenced by:
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Licensee/Administrator to submit LPA a copy of R1's service plan that is signed by facility and R1's responsible party. Facility/Administrator to submit a plan in writing to address how the facility will ensure that resident records are complete and current.
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Based on file reviewed, LPA observed that R1's service plan was incomplete as it was not signed by R1's responsible party.
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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: 06/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 06/29/2023 12:20 PM - 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: 06/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2023
Section Cited
CCR
87412(a)(13)(B)

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87412 Personnel Records: (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:(13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance:(B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).

Violation of this regulation is not met as evidenced by:
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Licensee/Administrator to review regulation 87412 Personnel Records and ensure each staff files have required documents maintained as specified in the regulations.
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Based on record review of personnel files, LPA did not observe documentation of criminal record clearance for S1 and S2.
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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: 06/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5