415600089-6-30-2026-14-AS-MHAN-DVJQUU-20260630122921

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600089
Report Date: 06/30/2026
Date Signed: 06/30/2026 12:29:49 PM

Document Has Been Signed on 06/30/2026 12:29 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 SENIOR HOME		FACILITY NUMBER:	415600089
ADMINISTRATOR/ DIRECTOR:	EHSANIPOUR, FERESHTEH		FACILITY TYPE:	740
ADDRESS:	1237 BALBOA AVENUE		TELEPHONE:	(650) 340-8789
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY: 6		CENSUS: 4	DATE:	06/30/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Administrator, Fereshteh Ehsanipour		TIME VISIT/ INSPECTION COMPLETED:	12:45 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 June 30, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregivers, Helen Soriano and LPA explained the purpose of the visit. The administrator, Fereshteh Ehsanipour arrived shortly thereafter and assisted with the rest of the inspection. LPA toured the facility inside out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, and backyard. The indoor and outdoor passageways were free of obstruction. The facility has 4 resident rooms (2 shared and 2 private rooms) with bathrooms and 1 staff room. Furniture and furnishings were observed to be sufficient. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas were observed clean and in operating condition. Comfortable temperature is maintained and lighting is sufficient for comfort. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time. Central storage for medications, sharps and chemicals were observed to be locked and inaccessible to residents in care. Hot water temperature in the kitchen and bathroom were measured at 116-119 degrees Fahrenheit. Fire extinguishers were checked. A review of (4) resident files was conducted and noted on the LIC 858. A review of (2) staff files was conducted and noted on the LIC 859.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/30/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 06/30/2026 12:29 PM - It Cannot Be Edited

Created By: Murial Han On 06/30/2026 at 11:37 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: BURLINGAME SENIOR HOME	FACILITY NUMBER: 415600089
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as S2 did not have a completed health screen which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/01/2026
	Plan of Correction
1 2 3 4	The administrator will submit a plan to ensure S2 completes a health screen and will provide a copy of the health screen to CCL by 7/1/2026. The administrator stated that she will send S2 to complete the health screen by 7/1/2026.

Type A

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/01/2026
	Plan of Correction
1 2 3 4	The administrator stated that she will submit the LIC 9182 and a copy of S2's ID to CCL to complete the criminal transfer process by 7/1/2026. The administrator will submit a plan of correction to ensure the facility is active on Guardian to complete the criminal background process moving forward. The administrator will provide a copy of the plan to CCL by 7/1/2026.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	April Cowan
NAME OF LICENSING PROGRAM MANAGER:

	Murial Han
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/30/2026 12:29 PM - It Cannot Be Edited

Created By: Murial Han On 06/30/2026 at 11:37 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: BURLINGAME SENIOR HOME	FACILITY NUMBER: 415600089
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87355(j)

Criminal Record Clearance

(j) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees in the individual's personnel file as required in Section 87412, Personnel Records. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as S1 and S2 did not have a copy of their criminal record clearance in their personnel file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/08/2026
	Plan of Correction
1 2 3 4	The administrator will develop a plan indicating that she will print a copy of documents and place it in their files.

Type B

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed R1, R3 and R4 did not have an updated reappraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/14/2026
	Plan of Correction
1 2 3 4	The administrator will submit a plan of correction to ensure reappraisals are completed accordingly and a copy of the completed reappraisals for R1, R3 and R4 to CCL by 7/14/2026.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	April Cowan
NAME OF LICENSING PROGRAM MANAGER:

	Murial Han
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/30/2026 12:29 PM - It Cannot Be Edited

Created By: Murial Han On 06/30/2026 at 11:37 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: BURLINGAME SENIOR HOME	FACILITY NUMBER: 415600089
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed R2 has a half rail by the bed without a physician's order which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/14/2026
	Plan of Correction
1 2 3 4	The administrator will submit a plan of correction to ensure there is a physician's order for postural support devices that are being utilize on residents and a copy of the plan and a copy of the physician's order for R2 CCL by 7/14/2026.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	April Cowan
NAME OF LICENSING PROGRAM MANAGER:

	Murial Han
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026

LIC809 (FAS) - (06/04)

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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 SENIOR HOME	FACILITY NUMBER: 415600089
	VISIT DATE: 06/30/2026

NARRATIVE

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During today's visit, the facility was issued a citation of 87405(d)(1)(2) - Administrator Qualifications and Duties due to the repeat citations and civil penalties that the facility have received from the previous annual inspections in 2024 and 2025.

During today's visit, civil penalty in the amount of $500 is being assessed for S2 who was hired on 6/17/2026 and started the on-the-job training at the facility on 6/26/2026 without a transfer of a criminal record clearance.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in additional civil penalties.

This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/30/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/30/2026 12:29 PM - It Cannot Be Edited

Created By: Murial Han On 06/30/2026 at 11:45 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: BURLINGAME SENIOR HOME	FACILITY NUMBER: 415600089
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87405(d)(1)(2)

87405 Administrator - Qualifications and Duties This requirement is not met as evidenced by: based on observation, record reviews and interviews, the facility has received multiple repeat deficiencies.
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above based on observation, record reviews and interviews, the facility has received multiple repeat deficiencies which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/01/2026
	Plan of Correction
1 2 3 4	The Administrator will review all the repeat deficienies that were obtained from 2024, 2025 and 2026 and develop a plan of correction for each repeat deficiency to ensure compliance and will submit a copy of the plan to CCL by 7/1/2026.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	April Cowan
NAME OF LICENSING PROGRAM MANAGER:

	Murial Han
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026

LIC809 (FAS) - (06/04)

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