<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508825
Report Date: 10/09/2024
Date Signed: 10/09/2024 12:19:54 PM

Document Has Been Signed on 10/09/2024 12:19 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:BURLINGAME VILLA, INC.FACILITY NUMBER:
410508825
ADMINISTRATOR/
DIRECTOR:		MEDORIO, ANAFACILITY TYPE:
740
ADDRESS:1117 RHINETTE AVENUETELEPHONE:
(650) 344-7074
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 27CENSUS: 25DATE:
10/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Administrator, Ana MedorioTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On October 9, 2024, Licensing Program Analyst (LPA) Murial Han conducted a Case Management visit to follow-up on two incidents that were reported by the facility. LPA met with the administrator and explained the purpose of today's visit.

On September 19, 2024 , the facility reported an incident that happened on 9/ 17/2024 that resident #1(R1) received medication that was intended for another resident.

On October 7, 2024, the facility reported an incident that happened on 10/06/2024 that resident #2 (R2) received both AM and PM medications during the AM shift.

During today's visit, LPA interviewed the administrator, the resident care coordinator, staff members and reviewed training records.

In regards to the incident that happened on 9/17/2024, the resident care coordinator stated that the shift manager/ Medication Technician (S1) placed R1's medication in R1's food and a caregiver (S2) mistakenly feed another resident's food that also consisted of medication.

According to S2, on the day of the incident, S2 was orienting a new staff who started to feed R1 and when S2 discovered that there was medication in the dessert, S2 instructed the new staff to stop feeding and immediately reported it to S1 which resulted S1 realizing that R1 was given another resident's medication. In addition, S2 stated that they have not observed medication in resident's food in the past, and this incident was the first time that they discovered medication in resident's food.

According to the administrator and resident care coordinator, S1 made a mistake and it was corrected immediately. They also stated that the caregivers were not suppose to administer medication as they were not trained.
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.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA interviewed 4 caregivers and all of them reported that they do not give medication to residents, the shift managers do.

After the incident, the facility completed a change of condition for R1 which consisted of reporting it to R1's provider, responsible party, CCL and Ombudsman. The facility monitored R1 and there was no adverse reaction noted.

In regards to the incident that happened on 10/6/2024, the administrator stated that the shift manager/med tech (S3) made a medication error by administering R2's AM and PM medications on the AM shift.

After the incident, the facility completed a change of condition for R2 that consisted of reporting it to R2's provider, responsible party, CCL and Ombudsman. The facility monitored R2 and there was no adverse reaction noted.

Based on the training records provided by the facility, LPA observed the annual training was completed by the shift managers and training was conducted after the incident that happened on 9/17/2024.

In addition, the administrator reported that the facility will have another training provided by an outside consultant company to ensure shift managers/med techs are educated on medication administration.

No deficiency cited today.

This report is reviewed and discussed with the administrator and 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
LIC809 (FAS) - (06/04)
Page: 2 of 2