Community Care Licensing

Document Has Been Signed on 02/22/2024 07:00 PM - It Cannot Be Edited

FACILITY NAME:	BURLINGAME SENIOR HOME 2		FACILITY NUMBER:	415600648
ADMINISTRATOR:	EHSANIPOUR, FERESHTEH		FACILITY TYPE:	740
ADDRESS:	1738 QUESADA WAY		TELEPHONE:	(650) 692-1838
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY: 6		CENSUS: 6	DATE:	02/22/2024
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Caregiver, Ligaya Munoz		TIME COMPLETED:	01:20 PM

SUPERVISORS NAME: Cara Smith LICENSING EVALUATOR NAME: Murial Han 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

Link to Parent Document Below:

FACILITY NAME: BURLINGAME SENIOR HOME 2	FACILITY NUMBER: 415600648
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2024

Type A

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 the administrator was not able to provide documentation of the drills for 2023 to present which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/23/2024
	Plan of Correction
1 2 3 4	The administrator will conduct a drill immediately and provide a copy of the staff in-service sign-in record of the drill to CCL by 2/23/2024. In addition, the administrator will provide a plan to CCL by 2/23/2024 to ensure drills are completed according to the regulation.

Section Cited

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

SUPERVISOR'S NAME: Cara Smith LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024

Link to Parent Document Below:

FACILITY NAME: BURLINGAME SENIOR HOME 2	FACILITY NUMBER: 415600648
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2024

Type B

Section Cited

CCR

87456(a)(2)

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. 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 2 out of 3 residents did not have documents to proof that preadmission appraisal were completed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/29/2024
	Plan of Correction
1 2 3 4	The administrator will develop a plan to ensure all pre-admission appraisal is completed and will provide a copy of the plan to CCL by 2/29/2024.

Type B

Section Cited

HSC

1569.695(d)

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. 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 the administrator was not able to provide proof that this plan was reviewed and updated accordingly which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/29/2024
	Plan of Correction
1 2 3 4	The administrator will provide a copy of the updated emergency disaster plan to CCL by 2/29/2024 and will submit a plan to CCL by 2/29/2024 to ensure compliance in the future.

SUPERVISOR'S NAME: Cara Smith LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024