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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601127
Report Date: 04/21/2022
Date Signed: 04/21/2022 11:45:20 AM


Document Has Been Signed on 04/21/2022 11:45 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:SERRA HIGHLANDS SENIOR LIVINGFACILITY NUMBER:
415601127
ADMINISTRATOR:DUENAS, JENNIFERFACILITY TYPE:
740
ADDRESS:501 KING DRIVETELEPHONE:
(650) 878-5111
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:120CENSUS: 61DATE:
04/21/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Interim Executive Director, Amanda North,TIME COMPLETED:
12:15 PM
NARRATIVE
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On April 21, 2022, Licensing Program Analysts (LPA) Komal Charitra conducted an unannounced plan of correction (POC) visit to verify and to confirm that the facility is in compliance with the citations that were issued on 4/8/2022. LPA Charitra met with Interim Executive Director, Amanda North, and explained the purpose of the visit.

On 4/8/2022, facility was cited for two Type B violations, California Code Regulation (CCR), 87206(a) Advertisement and License Number and 87109(b) Transferability of License. The plan of correction was due to CCL by 4/15/2022, however, the facility failed to provide CCL with a plan by the due. The following deficiencies will be cited again.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with Amanda North; a copy is provided with the appeals right.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/21/2022 11:45 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: SERRA HIGHLANDS SENIOR LIVING
FACILITY NUMBER: 415601127

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/28/2022
Section Cited

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87206 Advertisment and License Number: (a) In accordance with Health and Safety Code Sections 1569.68 and 1569.681, licensees shall reveal each facility license number in all public advertisements, including Internet, or correspondence.

Violation of this regulation is not met as evidenced by:
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Based on LPA’s observation, the facility is observed to be advertising online as Serra Highlands Senior Living and has signage of the facility name as Serra Highlands Senior Living outside the facility building without a valid RCFE License. Licensee has failed to operate consistent with licensure as ATRIA AT DALY CITY, which poses a potential health, safety, or personal rights risk to clients in care.
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Type B
04/28/2022
Section Cited

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87109(b) Transferability of License: The licensee shall notify the licensing agency and all residents receiving services, or their representatives, in writing as soon as possible and in all cases at least 30 days prior to the transfer of the property or business...as specified in Health and Safety Code Section 1569.191.
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This requirement was not met, as evidenced by absence of proof that written notice was issued to residents or their responsible parties. Licensee failed to ensure that proper notices were issued prior to doing business as Pacfica Senior Living, which poses a potential health, safety or personal rights risk to clients in care.

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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: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
LIC809 (FAS) - (06/04)
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