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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600089
Report Date: 08/02/2022
Date Signed: 08/02/2022 12:20:00 PM

Document Has Been Signed on 08/02/2022 12:20 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 SENIOR HOMEFACILITY NUMBER:
415600089
ADMINISTRATOR:EHSANIPOUR, FERESHTEHFACILITY TYPE:
740
ADDRESS:1237 BALBOA AVENUETELEPHONE:
(650) 340-8789
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 6CENSUS: 5DATE:
08/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Fereshteh EhsanipourTIME COMPLETED:
12:30 PM
NARRATIVE
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On 8/2/2022, Licensing Program Analysts (LPAs) Murial Han conducted an unannounced case management visit to deliver the findings in reference to complaint # 14-AS-20220609140245. LPA met with the administrator and explained the purpose of the visit.

During the course of the investigation, the allegation of staff leave residents unattended for extended period of time was deemed to be unsubstantiated. However, Staff #2 reported sleeping on the couch in the resident's living.

Based on the complaint investigation, the facility did not ensure to provide a comfortable living accommodations and privacy for residents and staff. This deficiency will be cited on LIC809D.

During the course of the investigation, the allegation of staff did not provide residents with walker was deemed unfounded. However, LPA observed resident #1 (R1)'s bed has two quarter bed rails installed by head of the bed and R1 reported facility staff placed another removable metal device by the foot of the bed and a dresser in middle space between the head and the foot of the bed.

Facility staff acknowledged the above devices were placed next to R1's bed and reported the intent was to prevent R1 from falling out of the bed.

According to the documents provided, there was no physician's order for any of the devices used above and administrator acknowledged that R1 used the quarter bed rails for reposition while in bed. However, there was no physician's order.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Murial Han
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.

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
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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Based on the complaint investigation, the facility did not obtain a physician's order and/or documentation for using the devices mentioned above and these devices were restricting R1's movement.

Deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with the administrator. A copy of this report and the Appeal Rights are provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Murial Han
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
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/02/2022 12:20 PM - It Cannot Be Edited


Created By: Murial Han On 08/02/2022 at 11:25 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: 08/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2022
Section Cited
CCR
87608(a)(1)

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87608- Postural Support..(a) Based on the individual's preadmission appraisal,..(1) Postural supports shall be.. to improve a resident's mobility and independent functioning..but not limited to, preventing a resident from falling out of bed, a chair, etc.
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The facility will reassess the devices that are currently being used and will obtain a physician's order for the devices that will be continued to use after the assessement, and provide documentation. The facility will remove the device(s) immediately that is not prescribed by the physician,
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This requirement is not met as evidenced by the facilty places devices next to resident #1's bed without a phsyician's order and staff reported the intent was to prevent resident #1 from falling out of bed which posed an immediate health risk to residents in care.
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The administrator will review this regulation and provide a copy of a signed acknowledgement statement after the review. In addition, the administrator will provide in-services to staff and provide a copy of the sign-in sheet by 8/4/22.
Type B
08/15/2022
Section Cited
CCR87608(a)(3)

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87608 Postural Supports..(a) Based on the individual's preadmission appraisal,.(3)A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record
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The administrator will provide in-services to staff and provide a copy of the sign-in sheet to CCL by the plan of correction due date 8/15/2022.
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This requirement is not met as evidenced by the facility did not obtain a written order from the physician for resident #1's quarter bed rails which poses a potential health risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jackie Jin
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/02/2022 12:20 PM - It Cannot Be Edited


Created By: Murial Han On 08/02/2022 at 11:28 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: 08/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2022
Section Cited
CCR
87307(a)

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87307 Personal Accommodations and Services..(a)Living accommodations and grounds..The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, ....
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The administrator will rearrange a sleeping accommodation for staff #2. Administrator will review the regulation, provide an in-service to staff and provide a copy of the
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This requirement is not met as evidence by Staff #2 reported sleeping in the resident's living room at night which poses a potential health risk to residents in care.
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in-service sign-in record to CCL by the plan of correction due date 8/15/2022.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Jackie Jin
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022


LIC809 (FAS) - (06/04)
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