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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600089
Report Date: 10/08/2020
Date Signed: 10/09/2020 12:51:24 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:BURLINGAME SENIOR HOMEFACILITY NUMBER:
415600089
ADMINISTRATOR:EHSANIPOUR, FERESHTEHFACILITY TYPE:
740
ADDRESS:1237 BALBOA AVENUETELEPHONE:
(650) 340-8789
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:6CENSUS: 5DATE:
10/08/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Fereshteh EhsanipourTIME COMPLETED:
02:15 PM
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On October 8, 2020 at 1:15pm, Licensing Program Analyst (LPA) Michael Garcia conducted an unannounced case management inspection in response to an unusual incident that the facility had self-reported. Due to COVID-19 pandemic, the inspection was conducted remotely via video call. The tele-inspection was conducted with Fereshteh Ehsanipour, administrator.

At 1:42pm, LPA interviewed and toured the inside of the facility with Fereshteh.

Fereshteh is to submit the facility’s staff schedule (LIC500), and Resident 1 (R1)’s Plan of Care, via email, to LPA at the end of business day.

Report was discussed with Fereshteh at the end of inspection. An electronic copy of the report was emailed to Fereshteh for signature.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Michael GarciaTELEPHONE: (650) 380-4608
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020
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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