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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 410508825
Report Date: 06/22/2022
Date Signed: 06/22/2022 02:27:24 PM

Unsubstantiated


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
03/10/2021 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210310121224
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: DATE:
06/22/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ana MedorioTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained an unexplained fracture while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day at 1300hrs, Licensing Program Analyst (LPA) Jaime Vado and Kevin Varilla conducted an unannounced complaint investigation visit to deliver findings regarding the received allegation. LPA met with administrator Ana and explained purpose of today's visit.

During the course of the investigation it was found that there were consistent checks on R1 through the night. During those night checks the resident was observed in bed with legs out of bed or sitting on the bed. There was no report of pain or of a fall to the caregivers by R1 during those night checks. Staff even assisted the resident to lay back down in bed or to move her legs back into bed and R1 still did not indicate any pain or report a fall. The following morning R1 reported the pain to facility staff and was sent to the hospital via 911 for evaluation where she was found to have a leg fracture. There was not enough evidence to show a lack of supervision or neglect by staff or the facility. This allegation is 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 at this time.

No citations issued. Report reviewed with Ana.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
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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