BURLINGAME SENIOR LIVING

Official classification

Type B

Official code

87755(c)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: 87755 Inspection Authority of the Licensing Agency (c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as during the inspection, the administrator was not able to locate Staff #5 (S5)'s personnel file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/06/2026 Plan of Correction The administrator will develop a plan to ensure compliance and will submit the plan of correction by 2/6/2026

Official classification

Type A

Official code

87303(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed the kitchen floor was dirty, dusty, greasy, and full of dark black partials which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/29/2026 Plan of Correction The administrator will develop a plan of correction to ensure the kitchen is clean and safe at all times. The plan of correction shall indicate the date (no later than 2/6/2026) that the facility will complete the cleaning of the kitchen and will provide photos to proof of completion. The administrator will provide a copy of the plan to CCL by 1/29/2026.

Official classification

Type A

Official code

87412(a)(13)(B)

Regulation authority

CCR

What the official deficiency says

(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). This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as during the annual inspection, LPA observed S1 was working in the kitchen without a criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/29/2026 Plan of Correction S1 was asked to leave the facility during the inspection. The administrator will develop a plan of correction to ensure all the staff members have completed the criminal background clearance process prior to work. The administrator will provide a copy of the plan of correction to CCL by 1/29/2025. A civil penalty of $500 is being assessed today.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as during the annual inspection, LPA observed S2 not associated with the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/29/2026 Plan of Correction The administrator will Associate S2 by the end of the day and the administrator will develop a plan to ensure all staff members are associated with the facility prior to work and will provide a copy of plan to CCL by 1/29/2026. A civil penalty of $100 is being assessed today.

Official classification

Type A

Official code

87411(d)

Regulation authority

CCR

What the official deficiency says

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed S2 did not complete the on-the-job training which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/29/2026 Plan of Correction The administrator will develop a plan to ensure all staff members received on-the-job training and will provide a copy of the plan to CCL by 1/29/2026.

Official classification

Type A

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed the last drill was completed on 4/17/2025 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/29/2026 Plan of Correction The administrator will develop a plan to ensure emergency drills are conducted accordingly and the plan shall indicate that the facility will conduct a drill no later than 1/30/2025. The administrator will provide a copy of the plan of correction to CCL by 1/29/2026.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as during the tour of the kitchen with the resident service director and the kitchen manager, LPA observed the ice machine has a layer of dust on the top, the green garage can has white, light brown and gray spots on it, there was a gray tray stored on one of the carts that was filled with black dirt, and a piece of dirty black metal device. In addition, the stove was observed to have yellow and brown grease which poses an immediate health, safety or personal rights risk to persons in care which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/06/2026 Plan of Correction The administrator will develop a plan of correction to ensure the kitchen is clean and safe at all times. The plan of correction shall indicate the date (no later than 2/6/2026) that the facility will complete the cleaning of the kitchen and will provide photos to proof of completion. The administrator will provide a copy of the plan of correction to CCL by 2/6/2026.

Official classification

Type B

Official code

1569.695(d)

Regulation authority

HSC

What the official deficiency says

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed the Emergency and Disaster Plan Annual Review was blank which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/06/2026 Plan of Correction The administrator will develop a plan to ensure the Emergency and Disaster Plan is being reviewed annually. The administrator will provide a copy of the plan of correction to CCL by 2/6/2026.

Official classification

Type A

Official code

75411(f)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: 87411 Personnel Requirements - General Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed S5 did not have a TB status which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/29/2026 Plan of Correction The administrator will develop a plan to ensure all facility staff members complete the TB requirement prior to work and will provide a copy of the plan to CCL by 1/29/2026. The plan shall indicate the date that S5 will complete the TB test and the date shall be no later than 2/4/2026. A civil penalty of $250 is being accessed for repeat violation.

Official classification

Type A

Official code

87468.1(a)(16)

Regulation authority

CCR

What the official deficiency says

87468.1Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16)To receive or reject medical care or other services. This requirement has not been met as evidenced by based on observation, record review and interview, S1 witnessed R1 was screaming and yelling and S2 and S3 were holding R1's arms in bed while administering medicine which posed an immediate health and safety risk to resident in care.

Official plan of correction

The administrator/ licensee will develop a plan of correction to indicate what was the facility's immediate action to ensure R1's safety. The plan shall also include what is the action that the facility will take to prevent this from happen again. The plan shall include staff education. The administrator will provide a copy of the plan to CCL by 11/14/2025.

Deadline recorded: Nov 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (a)Facility personnel shall at all times be.. and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by based on observation, interview and record review, the facility director provided an in-service on 10/8/2025 on Medication Pass that included residents shall not be forced to take medicine but S2 did not attend the in-service which posed an immediate health and safety risks to residents in care.

Official plan of correction

The administrator/licensee will develop a plan of correction to ensure staff attends all required training. The plan shall include what is the monitoring process to ensure staff members are competent after the training. . The administrator/licensee will provide a copy of the plan of correction to CCL by 11/14/2025.

Deadline recorded: Nov 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by based on observation, and interview R1 room's carpet was dirty, the heater was not working in, both elevators and the facility van were broken which poses an immediate health and safety risks to residents in care.

Official plan of correction

The Licensee will develop a plan to ensure the facility is clean, safe, sanitary and in good repair at all times; the plan shall indicate how the facility shall monitor the deficient areas, and it shall also include the time-frame for the elevator repair. and it shall be signed by the Licensee as the facility currently does not have a designated administrator.

Deadline recorded: Jul 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by the facility did not have a qualified administrator since March 2025 which poses an immediate health and safety risks to residents in care.

Official plan of correction

The licensee will develop a plan to ensure the facility has a qualified and current certified administrator and provide a copy of the plan of correction to CCL by 7/9/2025 and it shall be signed by the Licensee as the facility currently does not have a designated administrator.

Deadline recorded: Jul 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(b)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. This requirement is not met as evidenced by R1 was admitted to a room that was cold because the heater was malfunctioned which poses a potential health and safety risk to resident in care.

Official plan of correction

The Licensee will develop a plan to ensure residents are residing in a environment with comfortable temperature. The Licensee will provide a copy of the plan to CCL by 7/16/2025 and it shall be signed by the Licensee as the facility currently does not have a designated administrator.

Deadline recorded: Jul 16, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by one of the two facility elevators has been malfunctioned for more than a year and the facility was not able to provide documents to proof that the repair or replacement of the elevator is in progress which poses an immediately health and safety risk to residents in care.

Official plan of correction

The Licensee and/or the administrator will provide a plan indicating details/actions that the facility will take to either repair or to replace the elevator. The plan shall have estimated time-frame of completion. The Licensee and/or the administrator will provide a copy of the plan to CCL by 3/12/2025.

Deadline recorded: Mar 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(4)

Regulation authority

CCR

What the official deficiency says

(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: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 1 out of 5 staff was not associated with this facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/16/2025 Plan of Correction The administrator associated the staff identified during the visit. However, the administrator/licensee still needs to develop a plan in writing to ensure compliance prior to staff working at the facility. The administrator/licensee will provide a copy of the plan to CCL by 1/16/2025.

Official classification

Type A

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 3 out of 5 staff did not have training records indicating that their required annual training was completed in 2024 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/16/2025 Plan of Correction The administrator/licensee will develop a plan to ensure all required annual training is completed for facility staff and the plan shall indicate the date that the training will be completed for the 3 facility staff who were identified during the inspection. The administrator will provide a copy of the plan to CCL by 1/16/2025.

Official classification

Type B

Official code

87355(j)

Regulation authority

CCR

What the official deficiency says

(j) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees in the individual's personnel file as required in Section 87412, Personnel Records. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 4 out of 5 staff did not have the criminal record clearances in their personnel files which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/22/2025 Plan of Correction The administrator/licensee will develop a plan in writing to ensure compliance and will provide a copy of the plan to CCL by 1/22/2025.

Official classification

Type A

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General This requirement is not met as evidenced by: Based on observation, interview, record reviews 3 out of 5 staff files did not have a copy of their TB and Health Screen results. Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 2 out of 5 staff files did not have a copy of their TB and Health Screen results which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/16/2025 Plan of Correction The administrator/licensee will develop a plan to ensure compliance and the plan shall indicate when the staff will complete their health screening process and TB. The administrator/licensee will submit a copy of the plan to CCL by 1/16/2025.

Official classification

Type B

Official code

87465(a)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care..(a) A plan for incidental medical and dental care shall be developed by each facility...(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation.. This requirement is not met as evidenced by based on interviews and observations, residents are missing their appointments and not scheduling new appointments as the facility van is broken and they were not aware of the other means of transportation which poses a potential health risks to residents in care.

Official plan of correction

The administrator will provide a plan of correction in writing of what is the facility's plan to ensure that the residents are aware of the alternative transportation that the facility is offering while the van is being repaired. In addition, the plan shall include the estimated time for the van to be fixed. The administrator will provide a copy of the plan to CCL by 1/2/2025.

Deadline recorded: Jan 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia..(b) In addition to the requirements as specified in Section 87208, Plan of Operation,..(2) Safety measures to address behaviors such as wandering, aggressive behavior.. This requirement is not met as evidence by: based on interviews, observations and record reviews, R1 left the unit/facility unattended and was found by the courtyard in front of the facility and staff did not know how R1 got out which poses an immediate health and safety risks to residents in care.

Official plan of correction

The administrator/licensee will develop a plan to ensure residents will not leave the memory care unit unattended and the plan shall include staff training. The administrator/licensee will submit a copy of the plan to CCL by 11/18/2024.

Deadline recorded: Nov 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.2Additional Personal Rights of Residents(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities..2) To have their records and personal information remain confidential and to approve their release,... This requirement is not met as evidenced by based on record reviews and interviews, the facility shared R1's personal information with R1's relatives without R1's permission which poses a potential health risks to residents in care.

Official plan of correction

The administrator/licensee will develop a plan to ensure compliance and the plan will include staff education. A copy of the plan will be submitted to CCL by 8/7/2024.

Deadline recorded: Aug 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by R1 left the facility unassisted despite R1's LIC 602 indicated that R1 was not to leave the facility unassisted which posed an immediate health risks to residents in care.

Official plan of correction

The administrator will develop a plan to ensure compliance and the plan shall include the facility's protocols to prevent this incident from happening again. The plan shall include staff training. The administrator will submit a copy of the signed and dated plan to CCL by 4/5/2024 indicating when the training will be completed.

Deadline recorded: Apr 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 3 out of 4 staff members did not have a valid CPR/First Aid Certificate which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/31/2024 Plan of Correction The administrator will provide a plan to ensure compliance and the plan shall indicate the date that staff members would complete their CPR/First Aid training. In addition, the administrator will provide a copy of S1, S2, and S4's renewed CPR/First Aid certificates. The administrator will provide a copy of the plan to CCL by 1/31/2024

Official classification

Type A

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as several areas in the kitchen was observed to be dirty which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/31/2024 Plan of Correction The administrator will develop a plan to ensure compliance and the plan needs to indicate when the kitchen will be cleaned and how is it going to be maintained. The administrator will provide a copy of the plan to CCL by 1/31/2024 and submit photos to proof that the identified areas are cleaned.

Official classification

Type A

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as facility was not able to provide proof that drills were conducted accordingly which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/31/2024 Plan of Correction The administrator will develop a plan to ensure compliance and submit a copy of the plan to CCL by 1/31/2024.

Official classification

Type A

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

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: Based on record review and interviews conducted, facility acknowledged to not submitted CCL a incident report for an incident that occurred on July 12, 2023.

Official plan of correction

Facility will conduct an in-service training with Resident Care Director and Memory Care Director regarding reporting requirements. A civil penalty of $250 is assessed for repeat violation

Deadline recorded: Jul 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

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: (1) Obtain a California clearance or a criminal record exemption as required by the Department or.. Violation of this regulation is not met as evidenced by: Based on observations and record review, LPA observed S1 to not be fingerprint cleared.

Official plan of correction

S1 was immediately sent home during LPAs visit. Licensee will ensure fingerprints and associations are up to date. A civil penalty of $100 is being assessed.

Deadline recorded: Jul 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). Violation of this regulation is not met as evidenced by: Based on interviews conducted and files reviewed, R1 has a secondary diagnosis of dementia and is unable to leave the facility unassisted, however on July 12, 2023, R1 left the facility unassisted. In addition, according to staff interviewed R1 has left the facility mulitple times in the past without a staff member accompanying R1. Furthermore, LPA observed R1's service plan in a resident service plan binder on the front desk to indicate R1 is not allowed to leave the facility unassisted.

Official plan of correction

Facility will conduct an elopment in-service training with staff. All service plans on the front desk will be reviewed to ensure they are up to date. Facility will fax LPA a copy of list of residents who are able to leave the facility and not able to leave the facility unasissted which will be placed on the front desk at the facility.

Deadline recorded: Jul 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

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: Based on record review, LPA observed S1 and S2 to have fingerprint clearance, however was not associated to the facility.

Official plan of correction

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

Deadline recorded: Jun 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

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: Based on record review, the Licensee failed to submit two incident reports from 5/1/2023 and 5/23/2023 to CCLD.

Official plan of correction

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.

Deadline recorded: Jul 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

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: 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.

Official plan of correction

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. 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.

Deadline recorded: Jul 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

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: Based on file reviewed, LPA observed that R1's service plan was incomplete as it was not signed by R1's responsible party.

Official plan of correction

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.

Deadline recorded: Jul 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87412(a)(13)(B)

Regulation authority

CCR

What the official deficiency says

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: Based on record review of personnel files, LPA did not observe documentation of criminal record clearance for S1 and S2.

Official plan of correction

Licensee/Administrator to review regulation 87412 Personnel Records and ensure each staff files have required documents maintained as specified in the regulations.

Deadline recorded: Jun 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

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: 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.

Official plan of correction

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.

Deadline recorded: Jun 13, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(A)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted to the licensing agency...for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...(A) Death of any resident from any cause regardless of where the death occurred... Violation of this regulation is evidenced by: Based on record review, the Licensee/Administrator failed to report a death of a resident within 7 days of occurrence. It was observed on the death report submitted that R1 passed away on 3/21/23, however the death report was not submitted to CCL until 4/6/23.

Official plan of correction

Facility Administrator to read and review CCR 87211 and submit acknowledgment to LPA by 4/19/2023.

Deadline recorded: Apr 19, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.312

Regulation authority

HSC

What the official deficiency says

1569.312 Basic services requirements..Every facility required to be licensed under this chapter shall provide at least the following basic services: a) Care and supervision as defined in Section 1569.2. Violation of this regulation is evidenced by: Based on interviews conducted, 4/4 staff members and family interviewed stated that there were days they observed residents being left in soiled diapers.

Official plan of correction

Licensee shall develop a plan of action in writing describing how the facility shall ensure residents are not being left in soiled diapers. Plan of correction to include plan to train staff. Copy of training to be submitted to LPA by 4/19/2023

Deadline recorded: Apr 19, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times... Violation of this regulation is evidenced by: Based on observations and interviews conducted, LPA observed a hole on the 4th floor ceiling wall on 3/27/23 and 4/12/23. According to the Regional Vice President of Operations, Beau Ayers, the Maintenance Director has purchased materials for the ceiling and the repair date is Monday 4/17/2023.

Official plan of correction

Licensee/Administrator to submit a photo of the repaired ceiling to LPA by 4/19/2023. Licensee/Administrator to submit a copy of reciept of the purchased materials by 4/19/2023.

Deadline recorded: Apr 19, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87206(a)

Regulation authority

CCR

What the official deficiency says

ADVERTISEMENTS & LICENSE NUMBER 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. This requirement is not met, as facility is doing business as, and advertising as " Pacifica Senior Living Burlingame, " but without a valid RCFE license. Applicant has failed to operate consistent with licensure as ATRIA BURLINGAME, which poses a potential health, safety, or personal rights risk to clients in care.

Official plan of correction

Plan of correction to cease operating as Pacific Senior Living Burlingame to be submitted to CCLD BY DUE DATE

Deadline recorded: Mar 31, 2022. A deadline is not proof that correction was completed.