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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508825
Report Date: 09/02/2021
Date Signed: 09/02/2021 02:58:02 PM

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: 24DATE:
09/02/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ana MedorioTIME COMPLETED:
03:00 PM
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On this day at 1330hrs, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management in conjunction with opening a 10 day initial complaint investigation visit. LPA met with administrator Ana Medorio and explained purpose of today's visit which was to make observations regarding the masking of staff.

During today's visit LPA toured the facility independently and made observations on the ground floor and upper floor. LPA observed all staff wearing masks on this day. LPA observed at least six staff members wearing masks. Both floors observed all staff are wearing masks. LPA advised administrator to review the newest PIN regarding masking guidelines within the facility. She notified LPA that she conducted additional masking training on 08/05/21 and 08/06/21 regarding masking and posted additional masking reminders thorough out the facility. LPA did observe these masking signs during today's tour of the facility.

No citations issued.

Report is reviewed with administrator.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
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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