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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 410508825
Report Date: 11/04/2022
Date Signed: 11/04/2022 12:23:13 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
08/27/2021 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210827095852
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: 26DATE:
11/04/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Ana MedorioTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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- Staff did not notify resident's representative of reasons for changes in hospice status
- Staff not administering medications as prescribed by physician
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) conducted an unannounced complaint investigation visit to deliver the findings regarding the allegations received. LPA met with administrator Ana Medorio and explained the purpose of today's visit.

During the investigation LPA reviewed documentation from the facility, conducted interviews with staff and related parties to the allegation. It is discovered that the resident graduated from hospice care. LPA reviewing the hospice documents, including the discharge from hospice, the responsible party signed off on the hospice discharge indicating that she was notified. If this happened immediately LPA could not determine that, but does see evidence of the family being notified and signing off on this hospice change.

Continued on Page 2 ...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
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-20210827095852
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: BURLINGAME VILLA, INC.
FACILITY NUMBER: 410508825
VISIT DATE: 11/04/2022
NARRATIVE
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Page 2: LIC9099C - Investigation findings

In regards to the medication not being administered as prescribed, it is discovered when medication administration record (MAR) were reviewed by LPA, the medication order and dosage are on record as well as on the MAR, showing medications were being administered per doctor's order. Upon admission there was a mis-communication to the resident's responsible party about the new medication order as the medication had increased in frequency. LPA did not find evidence of facility over medicating as the medication order is present and facility is administering accordingly. There was a change from PCP to the facility's normal physician they use due to the mis-communications between the PCP and facility physician which may have caused confusion as the facility had the facility physician assess and prescribe medications based on a virtual assessment. LPA could not prove or disprove any medication mismanagement.

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 citation issued. Report is reviewed with administrator.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2