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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600648
Report Date: 02/13/2024
Date Signed: 02/13/2024 03:52:17 PM

Document Has Been Signed on 02/13/2024 03:52 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 HOME 2FACILITY NUMBER:
415600648
ADMINISTRATOR:EHSANIPOUR, FERESHTEHFACILITY TYPE:
740
ADDRESS:1738 QUESADA WAYTELEPHONE:
(650) 692-1838
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 6CENSUS: 6DATE:
02/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregiver, Ligaya MunozTIME COMPLETED:
01:00 PM
NARRATIVE
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On February 13, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with Caregiver, Ligaya Munoz, and caregiver, Isabelita Nojadera. Administrator, Fereshteh Ehsanipour was not available to join the inspection. LPA explained the purpose of the visit.

LPA toured the facility and grounds with caregiver. No accessible bodies of water or fire safety hazards observed. This is a single story facility with 6 resident bedrooms, 1 staff bedroom, 1 full bathroom and 5 half bathrooms.. LPA observed all 6 resident rooms; 1 with a full bathroom and 5 with half baths. Resident's rooms were observed to be private rooms. Bedrooms were equipped with the required furniture for resident to use, Bathrooms were equipped with grab bars, and non-skid mats. Hot water temperature was measured at 106- 110 degrees F.

LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable present. A comfortable temperature is maintained, lighting is sufficient for comfort.

Centrally stored medications, toxins, and sharps were observed to be unlocked and accessible to residents. LPA reviewed centrally stored medication and observed 2 medications for resident #1 (R1) to be expired.

LPA requests the following forms to be submitted to CCLD by 2/15/2024
  • LIC308 Designation of Administrative Responsibility
  • LIC309 Administrative Organization
  • Liability Insurance
  • Administrator Certificate


SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024
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 2
FACILITY NUMBER: 415600648
VISIT DATE: 02/13/2024
NARRATIVE
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LPA was not able to complete the inspection today and will return on another day as the resident and staff records were locked and not accessible for review. According to the staff, they do not have access to the files and the administrator is the only one who has the keys to the files.

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 civil penalties.

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


SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/13/2024 03:52 PM - It Cannot Be Edited


Created By: Murial Han On 02/13/2024 at 11:34 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 2
FACILITY NUMBER: 415600648

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 chemicals stored underneath the kitchen sink were unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
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4
The administrator will develop a plan to ensure all the toxins and chemicals are locked at all times. The administrator will provide a copy of the plan of correction and photos to proof that chemicals and toxins are locked to CCL 2/14/2024.
Type A
Section Cited
CCR
80065(i)(2)


This requirement is not met as evidenced by: Staff Association
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as S1 who was hired in March 2023 is not associated with the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
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2
3
4
The administrator will associate S1 immediately and provide proof of S1's association to CCL by 2/14/2024.
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:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/13/2024 03:52 PM - It Cannot Be Edited


Created By: Murial Han On 02/13/2024 at 11:34 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 2
FACILITY NUMBER: 415600648

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87113
Posting of License
The license shall be posted in a prominent location in the licensed facility accessible to public view.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA did not observed it was posted during tour which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
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The administrator will ensure the license is posted and provide a photo to CCL by 2/20/2024.
Type B
Section Cited
CCR
87468(c)(2)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA did not observed it was posted during the tour and according to the administrator, it fell and was not reposted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
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2
3
4
The administrator will ensure the license is posted and provide a photo to CCL by 2/20/2024.
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:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/13/2024 03:52 PM - It Cannot Be Edited


Created By: Murial Han On 02/13/2024 at 11:34 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 2
FACILITY NUMBER: 415600648

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA did not observed it was posted during the tour and according to the administrator, it fell and was not re-posted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
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The administrator will post the required posters and will provide a photo to CCL of the above poster by 2/20/2024.

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:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 02/13/2024 03:52 PM - It Cannot Be Edited


Created By: Murial Han On 02/13/2024 at 11:34 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 2
FACILITY NUMBER: 415600648

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(d)
Personal Rights of Residents
(d) Licensees shall post the personal rights, nondiscrimination notice, and complaint information specified above in English, and, in any other language in which at least five (5) percent of the residents can only read that other language.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA did not observed it was posted during the tour and according to the administrator, it fell and was not reposted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
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The administrator will post the required posters and will provide a photo to CCL of the above poster by 2/20/2024.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/13/2024 03:52 PM - It Cannot Be Edited


Created By: Murial Han On 02/13/2024 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 2
FACILITY NUMBER: 415600648

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)


This requirement is not met as evidenced by: centrally stored medication observed to be not locked and accessible to residents in care.
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as centrally stored medication observed to be not locked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
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2
3
4
The administrator shall develop a plan to ensure centrally stored medication is locked at all times. The administrator will submit a copy of the plan and phots to proof compliance to CCL by 2/14/2024.
Type A
Section Cited
CCR
87468.1(a)(2)


This requirement is not met as evidenced by:Personal Rights of Residents in All Facilities
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 2 of resident #1's medications were expired which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
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2
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The administrator will review all resident's medication to ensure all medications are not expired and will provide a statement to CCL by 2/14/2024 stating this process has been completed . In addition, the administrator will provide a plan to CCL by 2/14/2024 to ensure compliance.
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:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/13/2024 03:52 PM - It Cannot Be Edited


Created By: Murial Han On 02/13/2024 at 12:11 PM
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 2
FACILITY NUMBER: 415600648

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87755(c)


This requirement is not met as evidenced by:Inspection Authority of the Licensing Agency
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as resident and staff records/files were locked and inaccessible for LPA to review which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
1
2
3
4
The administrator shall develop a plan to ensure records are available to inspect according to the regulation. The administrator shall submit a copy of the plan to CCL by 2/14/2024.
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.
SUPERVISOR'S NAME:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024


LIC809 (FAS) - (06/04)
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