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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600648
Report Date: 02/22/2024
Date Signed: 02/22/2024 12:57:50 PM


Document Has Been Signed on 02/22/2024 12:57 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:
02/22/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Caregiver, Ligaya MunozTIME COMPLETED:
01:10 PM
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On February 22, 2024, Licensing Program Analyst (LPA) conducted an unannounced Plan of Correction (POC) visit to follow up on deficiencies cited on February 13, 2024 during an annual inspection.

Upon arrival, LPA was greeted by caregiver, Ligaya Munoz and LPA explained the purpose of the visit. The administrator, Fereshteh Ehsanipour arrived later and assist with the visit.

During today's visit LPA observed the following deficiency was not corrected. The administrator submitted a plan of correction on February 14, 2024 stating that facility staff will have access to all locked record drawers. However, upon arrival, facility staff was not able to provided staff and residents records for inspection and they stated that they did not have the key to open the locked record drawers. LPA was not able to conduct record reviews until the arrival of the administrator who has the key(s) the lock drawers.

87755 Inspection Authority of the Licensing Agency..(c)The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b).

Due to the above observation and deficiency not being corrected, a civil penalty is being assessed in the amount of $100 a day from 2/15/2024 through 2/22/2024 and will continue to accrue until corrected.

A total civil penalty of $800 is being assessed.

LPA observed the following deficiencies were corrected: 87309(a), 87113, 80065(i)(2), 87468(c)(2), 87468(c)(2)(A), 87468(d), 87465(h)(2), 87468.1(a)(2).

This report is reviewed and discussed with the administrator; A copy is provided with the appeal rights..
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
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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