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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508825
Report Date: 12/04/2020
Date Signed: 12/29/2020 09:56:03 AM

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:BURLINGAME VILLA, INC.FACILITY NUMBER:
410508825
ADMINISTRATOR:MEDORIO, ANAFACILITY TYPE:
740
ADDRESS:1117 RHINETTE AVENUETELEPHONE:
(650) 344-7074
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:27CENSUS: 26DATE:
12/04/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ana MedorioTIME COMPLETED:
02:50 PM
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On this date, Licensing Program Analyst (LPA) Michael Garcia conducted a Case Management visit to provide Technical Assistance (TA) to the facility regarding COVID-19. Due to the pandemic, the visit was conducted remotely, via video call. The TA visit was conducted with Ana Medorio, administrator, along with Janet Hayes, BSN, RN of the California Department of Public Health, and Brenda Chan, Licensing Program Manager.

The facility's COVID-19 protocol was discussed. Public areas of the facility were toured, along with the staff and laundry room.

The visit resulted with the following recommendations:
- All staff should be in N95s until cleared by San Mateo DPH.
- All staff and residents who test negative during this first round of mass (response) testing should be retested 7 days after the first test. If anyone tests positive during the first or second mass testing, the process starts over with that new positive date.
- Once cleared, the facility should restart surveillance testing of 25% of the staff every 7 days.
- Continue to isolate until cleared by county DPH.
- Should any additional residents test positive, positive residents should have a separate caregiver that is not caring for any negative residents and that dedicated caregiver is not commingling with other negative caregivers.

Report was reviewed and discussed with the administrator. An electronic copy of the report was emailed to Administrator for signature.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Michael GarciaTELEPHONE: (650) 380-4608
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2020
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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