415600089-8-2-2022-14-AS-KHOS-CHJNUP-20220822104642

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600089
Report Date: 08/02/2022
Date Signed: 08/02/2022 12:22:46 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
06/09/2022 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220609140245

FACILITY NAME:	BURLINGAME SENIOR HOME		FACILITY NUMBER:	415600089
ADMINISTRATOR:	EHSANIPOUR, FERESHTEH		FACILITY TYPE:	740
ADDRESS:	1237 BALBOA AVENUE		TELEPHONE:	(650) 340-8789
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY:	6	CENSUS: 5	DATE:	08/02/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator, Fereshteh Ehsanipour		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff leave residents unattended for an extended period of time.

INVESTIGATION FINDINGS:

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On 8/2/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220609140245. LPA met with the administrator and explained the purpose to today's visit.

Regarding allegation of staff leave residents unattended for an extended period of time, during the investigation, the reported party stated that resident #1 (R1) is being assisted to bed after dinner and there was no staff at the facility to provide care until the next morning.

During the investigation, LPA interviewed R1 who stated that upon admission, he/she was provided a bell to be utilized when he/she was in bed and R1 stated that there were staff at night to assist when needed. LPA observed a silver metal bell placed next to R1's bed.

LPA interviewed resident #2 (R2) and resident #3 (R3) and both of them stated that there were staff at night and they used their call light for assistance when needed,

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

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 4

Control Number 14-AS-20220609140245

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 SENIOR HOME	FACILITY NUMBER: 415600089
	VISIT DATE: 08/02/2022

NARRATIVE

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LPA interviewed the administrator who stated that there were staff providing care and supervision all day and night. LPA reviewed the LIC 500 (Personnel Report) and it revealed 24 hour staffing coverage.

In addition, LPA interviewed Staff #1 (S1) and Staff #2 (S2) and both of them stated that they worked on the night shift several times a week. They also reported that they sleep during the night and get up to provide assistance when residents rang their call bell. S1 reported sleeping in a room behind the kitchen and S2 reported sleeping on the couch in the living that is shared with the residents. This is a deficiency and will be cited on LIC 809 under Personal Accommodations and Services as the facility did not provide comfortable living accommodations and privacy for the residents and staff.

Base on record review and interviews during the course of investigation, this allegation is unsubstantiated.

Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

This report is discussed with the administrator. A copy is provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
06/09/2022 and conducted by Evaluator Murial Han

COMPLAINT CONTROL NUMBER: 14-AS-20220609140245

FACILITY NAME:	BURLINGAME SENIOR HOME		FACILITY NUMBER:	415600089
ADMINISTRATOR:	EHSANIPOUR, FERESHTEH		FACILITY TYPE:	740
ADDRESS:	1237 BALBOA AVENUE		TELEPHONE:	(650) 340-8789
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY:	6	CENSUS: 5	DATE:	08/02/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator, Fereshteh Ehsanipour		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility does not have night staff.
Staff did not provide residents with walker.

INVESTIGATION FINDINGS:

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On 8/2/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220609140245. LPA met with administrator and explained the purpose to today's visit.

Regarding allegation of- facility does not have night staff, the reporting party stated that the facility did not have staff after they assisted resident #1 (R1) back to bed after dinner.

As part of the investigation, LPA interviewed 3 residents including the resident in question and all of them reported that there were staff at night after they go to bed.

In addition, LPA interviewed facility staff, and administrator and all of them stated that there are staff at the facility all day and night.

Furthermore, LPA reviewed the documents - LIC 500 Personal Report that revealed 24/7 staff coverage at the facility.

Based on this investigation, this complaint allegation is determined to be unfounded, meaning that the allegation could not have happened and/or is without a reasonable basis.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 14-AS-20220609140245

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 SENIOR HOME	FACILITY NUMBER: 415600089
	VISIT DATE: 08/02/2022

NARRATIVE

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Regarding to staff did not provide residents with walker, the reporting party stated that the facility staff took away resident #1 (R1)'s walker after they assisted R1 back to bed.

As part of the investigation, LPA interviewed R1 who stated that the walker was placed by the head of the bed when she is bed. However, R1 also reported not being able to reach for the walker as it was blocked by the quarter bed rails at the head of the bed, the removable metal device placed by the foot of the bed and the dresser in between the head and the foot bed rails.

LPA reviewed the medical documents provided by the facility, there was no physician's order and/or notes concerning the above devices.

Based on this investigation, this complaint allegation is determined to be unfounded, meaning that the allegation could not have happened and/or is without a reasonable basis as R1 and staff reported that the walker was placed next to the bed. However, the additional observation concerning the devices that facility placed next to R1's bed will be cited on a LIC809 under Postural Support.

This report is reviewed and discussed with the administrator. A copy is provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC9099 (FAS) - (06/04)

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