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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600191
Report Date: 04/08/2022
Date Signed: 04/08/2022 10:10:33 AM


Document Has Been Signed on 04/08/2022 10:10 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:ATRIA DALY CITYFACILITY NUMBER:
415600191
ADMINISTRATOR:AMANDA NORTHFACILITY TYPE:
740
ADDRESS:501 KING DRTELEPHONE:
(650) 878-5111
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:120CENSUS: 62DATE:
04/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Interim Executive Director, Amanda North TIME COMPLETED:
10:45 AM
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On April 8, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit. LPA met with Interim Executive Director, Amanda North and explained the purpose of the visit.

During a complaint investigation to this facility, licensed as Atria at Daly City #415600191, LPA Charitra observed the facility to be advertising as Serra Highlands Senior Living without an RCFE License. In addition, LPA Charitra observed facility to be advertising online as Serra Highlands and has signage for the facility name as “Serra Highlands Senior Living” outside the facility building. Serra Highlands Senior Living has submitted an application that is pending. The licensee has failed to clarify status and to demonstrate accountability. Licensee failed to be responsible to communicate with the Department regarding the following changes to the facility.

During the investigation of complaint control number 14-AS-20220222113600, LPA Charitra discovered that the facility failed to report an incident that occurred on February 10, 2022. According to the Interim Executive Director, Amanda North, the facility failed to report or send an incident report to Licensing as required due to the transition from Atria at Daly City to Serra Highlands Senior Living. Section 87211, Reporting Requirements, states, 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 Title 22 regulations.

During the same investigation of complaint control number 14-AS-20220222113600, LPA Charitra was informed that during the transition from Atria at Daly City to Serra Highlands Senior Living, there was a new Interim Executive Director that was appointed and new staff who had been hired. Staff interview indicated that they did not have any knowledge of Resident’s (R1’s) baseline and condition because they were new to the facility. This indicates that facility staff are not competent to provide the necessary needs and services to resident’s in care.

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.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022
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 4


Document Has Been Signed on 04/08/2022 10:10 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: ATRIA DALY CITY
FACILITY NUMBER: 415600191

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/09/2022
Section Cited

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87205 Accountability of Licensee Governing Body: (a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. (b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability.

Violation of this regulation is not met as evidence by:
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The licensee failed to clarify status and demonstrate accountability. In addition, the Licensee failed to be responsible to communicate with the Department regarding the following changes to the facility.
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Type B
04/15/2022
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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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: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 04/08/2022 10:10 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: ATRIA DALY CITY
FACILITY NUMBER: 415600191

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/15/2022
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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Type B
04/15/2022
Section Cited

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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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Facility failed to report an incident that occurred on February 10, 2022 as required to Licensing. In addition, facility failed to submit a written report within 7 days of the occurrence date of the incident.
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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: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 04/08/2022 10:10 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: ATRIA DALY CITY
FACILITY NUMBER: 415600191

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/15/2022
Section Cited

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87411(a) Personnel Requirements: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...

Violation of this regulation is not met as evidenced by:
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Based on interviews and information conducted during a complaint investigation, staff did not have knowledge regarding a resident’s baseline or condition when in care. In addition, staff indicated that during the switch from Atria at Daly City to Serra Highlands Senior Living, new staff came on board.
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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: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4