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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508825
Report Date: 05/02/2024
Date Signed: 05/02/2024 04:54:26 PM


Document Has Been Signed on 05/02/2024 04:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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
ADMINISTRATOR:MEDORIO, ANAFACILITY TYPE:
740
ADDRESS:1117 RHINETTE AVENUETELEPHONE:
(650) 344-7074
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:27CENSUS: 27DATE:
05/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Ana MedorioTIME COMPLETED:
12:40 PM
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On May 2, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA was met with the administrator, Ana and LPA explained the purpose of the visit.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Comfortable temperature is maintained and lighting is sufficient for comfort.

This is a two story facility. On the 1st floor, there are 10 resident private rooms with their own bathrooms, one common bath/shower room, dining area, and linen room. On the 2nd floor, there are 14 resident room(shared and private rooms) but the rooms do not have their own bathrooms; the bathrooms and showers rooms are located in the common area, there is also a dining room, staff lounge, and the housekeeping room.

LPA observed the bathrooms and showers are equipped with paper towels, soap, grab bars, and non-skid mats. Hot water temperatures were measured at 105- 108 degrees F. 2 days for perishables and & 7 days non-perishable food were observed to be present.

Facility is equipped with call system in the resident rooms, resident bathrooms, common shower rooms and common bathrooms. Fire extinguishers were last inspected on 5/30/2023, Fire drill records were reviewed to be adequate.

A review of (5) facility resident records was conducted.
A review of (5) facility staff records was conducted.

Medications, chemicals and toxic were observed to be locked and inaccessible to residents in care.

No deficiency cited today; a copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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