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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 410508825
Report Date: 06/18/2025
Date Signed: 06/18/2025 10:08:23 AM

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
04/29/2025 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250429102905
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: 27DATE:
06/18/2025
UNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Administrator, Ana MedorioTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff do not prevent private caregiver from inappropriately speaking to residents
Staff do not prevent private caregiver from interfering with residents' activities
INVESTIGATION FINDINGS:
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On June 18, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to delivery the complaint investigation findings. LPA met with the administrator and explained the purpose of today's visit.

Regarding to the allegation of- staff do not prevent private caregiver from inappropriately speaking to residents, the reporting party stated that the facility has a private caregiver from a home care agency who yells at other residents and one day, a facility caregiver was trying to encourage a resident to take a shower, this private caregiver interfered, yelled at the resident and tried to force the resident to take a shower. The reporting party stated that most of the residents at the facility suffers from Dementia with some sort of behaviors including his/her loved one so he/she did want this private caregiver to yell at his/her loved one.

As part of the investigation, LPA interviewed the administrator, the staff members, and the responsible party who hired the private caregiver.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
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 2
Control Number 14-AS-20250429102905
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: 06/18/2025
NARRATIVE
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According to the administrator, she has never observed the private caregiver speaking inappropriately to residents and staff and no one has brought it to her attention as well. The administrator also stated that the responsible party who hired the private caregiver visited the resident almost daily and is very satisfied with the services that the private caregiver is providing.

According to the person who hired the private caregiver, he/she stated that they visited the resident almost daily and has not witnessed any inappropriateness from the private caregiver to the residents. They also stated that they trust the private caregiver and they have worked with this person for many years.

According to the facility staff, they have not witnessed the private caregiver speaking inappropriately to the residents and they reported that there was one time the private caregiver attempted to assist them with calming down a resident who was yelling and screaming but he/she was not rude and/or disrespectful to the resident.

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

Regarding to the allegation of - staff do not prevent private caregiver from interfering with residents' activities, the reporting party stated the private caregiver takes the television remote, turns off the television and hides the remote, resulting in residents not able to watch television as an activity.

As part of the investigation, LPA interviewed the administrator and the facility staff.

The administrator denied the allegation and stated that she has not observed this behavior from the private caregiver nor it was reported to her.

LPA interviewed the facility staff from different shifts and all of them stated that they have not witnessed such behavior from the private caregiver.

Based on these observations, and interviews 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: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2