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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508825
Report Date: 11/13/2025
Date Signed: 11/13/2025 12:44:19 PM

Document Has Been Signed on 11/13/2025 12:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:BURLINGAME VILLA, INC.FACILITY NUMBER:
410508825
ADMINISTRATOR/
DIRECTOR:		MEDORIO, ANAFACILITY TYPE:
740
ADDRESS:1117 RHINETTE AVENUETELEPHONE:
(650) 344-7074
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 27CENSUS: 27DATE:
11/13/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Resident Coordinator, Madeline TignoTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
NARRATIVE
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On 11/13/2025, Licensing Program Analyst (LPA) conducted an unannounced case management visit to follow- up on an incident that was reported by the facility. LPA met with Resident Coordinator, Madeline Tigno and explained the purpose of today's visit.

On 11/10/2025, CCL received an unusual incident/injury report from the facility reporting an incident that occurred on 11/6/2025 in which staff #1 (S1) gave resident #1 (R1) medication that was intended for resident #2 (R2).

During today visit, LPA interviewed S1 who stated that when she returned from her lunch break, R1 usually sits in the dining room so she would give R1 medication. However, on the day of the incident, she noticed R1 was not in the dining room so she asked staff to get R1 to the dining room while preparing medication for R2. When she was about to give R2's medication to R2, R1 came into the dining room and she got distracted so she gave R2's medication to R1. S1 acknowledged that she did not ensure it was the Right Resident and the Right Medication prior to giving the medication to R1.

Based on training records, S1 was trained in September 2023, September 2024 and on 11/6/2025 on Medications/ Medication Errors/Narcotics and S1 stated that the training covered " The Six Rights" of medication administration.

Based on interview, records review and observation, deficient is cite for this incident because the S1 was trained on " The Six Rights" of Medication Administration, however, it was not followed while giving medication to R1 resulting in R1 received medication that was intended for R2.

Based on observation, record review, and interviews deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the Resident Coordinator; A copy is provided with appeal rights.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 11/13/2025 12:44 PM - It Cannot Be Edited


Created By: Murial Han On 11/13/2025 at 12:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: BURLINGAME VILLA, INC.
FACILITY NUMBER: 410508825

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/14/2025
Section Cited
CCR
87411(a)

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87411 Personnel Requirements - General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirment is not met
as evidenced by while giving medication, S1 did not ensure it
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The administrator/licensee shall develop a plan to ensure the facility has a process to monitor the competency of staff members with medication administration after training.
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was right the medicaiton and the right resident which resulted in R1 who was giving medication that was intended for R2 which poses an immediate health and safety risk to residents in care.
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The administrator/ licensee will provide a copy of the plan to CCL by 11/14/2025.

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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2025


LIC809 (FAS) - (06/04)
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