Burlingame Senior Living

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.

Keep bath, laundry and kitchen floors clean

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.

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.

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.

Maintain facility in clean, safe, sanitary condition

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.

Request a transfer of criminal record clearance

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.

On-the-job training requirements

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.

Collect criminal clearance or exemption documentation

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.

Authority to audit and copy facility records

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.

Right to accept or decline care or services

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.

Facility personnel sufficiency and competence

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 asevidenced 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.

Maintain facility in clean, safe, sanitary condition

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.

Maintain comfortable room temperature at all times

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.

Certified administrator requirements and substitute coverage

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.

Maintain facility in clean, safe, sanitary condition

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.

Request transfer of criminal record exemption

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.

Health screening and fitness requirements

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.

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.

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.

Provide assistance for residents medical needs

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.

Night supervision when dementia residents require it

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.

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.

Care and supervision as defined by statute and rules

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.

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.

Kitchen sanitation against contamination sources

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.

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.

Report specified resident events within seven days

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.

Submit and maintain current mailing address

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.

Care and supervision as defined by statute and rules

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.

Update reappraisal at required intervals

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.

Maintain separate complete record for each resident

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.

Report specified resident events within seven days

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.

Obtain required California clearance or exemption

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.

Collect criminal clearance or exemption documentation

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.

Update reappraisal at required intervals

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.

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.

Maintain facility in clean, safe, sanitary condition

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.

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.

ADVERTISEMENTS & LICENSE NUMBERIn 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.