410508825-10-9-2024-14-AS-ACON-DA4QFX-20241016120836

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 410508825
Report Date: 10/09/2024
Date Signed: 10/09/2024 12:23:27 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
08/20/2024 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240820082442

FACILITY NAME:	BURLINGAME VILLA, INC.		FACILITY NUMBER:	410508825
ADMINISTRATOR:	MEDORIO, ANA		FACILITY TYPE:	740
ADDRESS:	1117 RHINETTE AVENUE		TELEPHONE:	(650) 344-7074
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY:	27	CENSUS: 25	DATE:	10/09/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator, Ana Medorio		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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Facility personnel are not sufficient in numbers to meet residents' needs.
Facility staff failed to observe resident for physical changes.
Facility staff failed to seek timely medical attention for resident.
Facility failed to follow infection control plan.

INVESTIGATION FINDINGS:

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On October 9, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced complaint investigation visit to deliver the findings. LPA met with the administrator and explained the purpose of today's visit.

Regarding to the allegation of- facility personnel are not sufficient in numbers to meet residents' needs, the reporting party stated the facility did not have sufficient staff to care for resident #1 (R1) because during a visit in October 2023, the reporting party observed R1 looked and smelled bad and they can not find anyone to work at the facility.

As part of the investigation, LPA observed R1, interviewed the administrator, R1's responsible party and R1's family member.

During the visit on 8/27/2024, LPA observed R1 who was in the room with a family member and R1 appeared with bright affect, cleaned, and well- groomed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 14-AS-20240820082442

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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
	VISIT DATE: 10/09/2024

NARRATIVE

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LPA interviewed the administrator who denied the allegation and stated that the facility has sufficient staff to care for the residents and the facility just hired several new staff members. In addition, the administrator stated that she has good communication with R1's responsible party and this allegation was not brought up by the responsible party who visited R1 on a regular basis.

LPA interviewed R1's responsible party who stated that for the most part, the facility has sufficient staff to care for R1 but there were times when R1 had to wait a little longer for assistance as the staff was busy with other residents.

LPA interviewed R1's family member who visited R1 regularly and stated that this facility is the best place for R1 and he/she has not observed R1 to have unpleasant odor and/or unkempt during the visits.

After the investigation, this allegation is deemed to be unsubstantiated.

Regarding to the allegation of- facility staff failed to observe resident for physical changes, the reporting party stated that during a visit in Oct 2023, R1 had black and blue bruises all over R1's face.

As part of the investigation, LPA interviewed the responsible party, the family member, and reviewed documents.

According to R1's responsible party and a family member, the facility was aware of the black and blue bruises on R1's face because in Oct 2023, they were notified by the facility that R1 had an accident which resulted black and blue bruises on R1's face. They stated that after the accident, the facility implemented safety measures to ensure R1's safety.

Based on the documents provided by the facility, there was an incident report completed by the facility in Oct 2023 reporting R1's accident and the report indicated that it was reported to the responsible party.

After the investigation, this allegation is deemed to be unsubstantiated.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 14-AS-20240820082442

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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
	VISIT DATE: 10/09/2024

NARRATIVE

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Regarding to the allegation of- facility staff failed to seek timely medical attention for resident, the reporting party stated that during a visit in Oct 2023, he/she noticed R1 had classic signs of Urinary Tract Infection (UTI) and the facility did not notice it.

As part of the investigation, LPA interviewed the administrator and R1's responsible party.

According to the Administrator, R1 has recurrent UTI and R1 is on a routine medication for it. The administrator stated that when the facility was notified by R1's responsible party that R1 may have UTI, the facility took action right away and R1 was prescribed a medication for UTI.

LPA interviewed R1's responsible party who validated the information that was provided by the administrator and stated that the facility did seek for medical attention right away when they were notified that R1 may have UTI. In addition, the responsible party stated the facility has always kept him/her in the loop of communication with R1's condition.

After the investigation, this allegation is deemed to be unsubstantiated.

Regarding to the allegation of - facility failed to follow infection control plan, the reporting party stated that R1 had COVID-19 but there was no signs, and no PPE supplies indicating that R1 had COVID-19.

As part of the investigation, LPA toured the facility, interviewed the administrator, R1's responsible party, and R1's family member.

During the visit on 8/27/2024, LPA observed a sign by the door alerting visitors of facility's COVID-19 status but LPA did not observe any PPE supplies set-up inside the facility. The administrator stated that PPE isolation carts were removed after everyone tested negative, however, they were placed in the hallway during outbreak.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 14-AS-20240820082442

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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
	VISIT DATE: 10/09/2024

NARRATIVE

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During the tour, LPA also observed facility has adequate PPE supplies.

LPA interviwed R1's responsible party and R1's family member and they stated that the facility have adequate PPE supplies during the outbreak and there was a sign on the door informing the visitors. The responsible party stated that the facility informed him/her that R1 tested positive for COVID-19 and he/she informed the people who visited R1 on a regular basis.

After the investigation, this allegation is deemed to be unsubstantiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated.

The report is reviewed and discussed with the administrator.

A copy is provided.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC9099 (FAS) - (06/04)

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