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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600648
Report Date: 02/28/2024
Date Signed: 02/28/2024 10:06:25 AM


Document Has Been Signed on 02/28/2024 10:06 AM - 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:
02/28/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregiver, Ligaya MunozTIME COMPLETED:
10:15 AM
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On February 28, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced plan of correction visit to follow up on a civil penalty that was assessed on 2/22/2024. LPA met with caregiver, Ligaya and explained the purpose of the visit.

On February 22, 2024. LPA conducted an unannounced Plan of Correction visit to follow up on the citations that were issued during the annual visit on February 13, 2024. During the visit, LPA reviewed and validated the plan of correction that was submitted by the facility and cleared 8 out of 9 citations. However, LPA observed the remaining citation of 87755(c) Inspection Authority Of The Licensing Agency was not corrected and due to the citation not being corrected by 2/14/2024, a civil penalty in the amount of $800 was assessed from 2/15/2024 through 2/22/2024.

During today’s visit, LPA interviewed staff and observed the above citation has been corrected and citation is now cleared. Civil penalties will be stopped on 2/23/2024.

This report is reviewed and discussed with caregiver; A copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
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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