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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 410508825
Report Date: 10/15/2021
Date Signed: 10/15/2021 02:18:44 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/31/2020 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20201231163308
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: 25DATE:
10/15/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ana MedorioTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
-Suspicious death
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day at 1400hrs, Licensing Program Analyst (LPA) Jaime Vado and Komal Charitra met with Ana Medorio, administrator, to conduct an unannounced complaint visit to deliver the finding regarding the above allegation.

According to hospice records, on August 22, 2020, Resident 1 (R1) was admitted to hospice care.

On December 1, 2020, hospice nurse noted that R1's left great toe wound was purple and dry, no drainage. Gauze was put in between the second toe, due to second toe being red. The second toe did not have an open wound.

On December 8, 2020, R1's great left toe was noted as dark purple and unbleachable.

On December 14, 2020, a facility staff member contacted the hospice agency to request to have R1 be checked on the next visit due to R1’s coccyx area was wrinkled, and the skin had been removed.

On December 15, 2020, R1's great let toe wound re-opened and was black. The skin on the toe next to the black toe was noted to be opening. R1's coccyx area was also opened.

On December 25, 2020, facility provided end of life care and R1 passed away on the same day. The cause of death was due to natural causes according according to death certificate.

This agency has investigated the complaint alleging suspicious death. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

Report was reviewed and discussed with the administrator.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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