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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600648
Report Date: 03/11/2025
Date Signed: 03/11/2025 05:22:53 PM

Document Has Been Signed on 03/11/2025 05:22 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:BURLINGAME SENIOR HOME 2FACILITY NUMBER:
415600648
ADMINISTRATOR/
DIRECTOR:		EHSANIPOUR, FERESHTEHFACILITY TYPE:
740
ADDRESS:1738 QUESADA WAYTELEPHONE:
(650) 692-1838
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 6CENSUS: 6DATE:
03/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Fereshteh EhsanipourTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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On March 11, 2025 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with Caregiver, Ligaya Munoz, and caregiver, Isabelita Nojadera. LPA explained the purpose of today's visit. Administrator, Fereshteh Ehsanipour arrived shortly thereafter and assisted with the inspection.

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 108- 117 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 and sharps were observed to be unlocked and accessible to residents in care. Toxins, chemicals and disinfectants were observed to be locked and inaccessible to residents.

Upon entrance, staff #2 was not able to provide staff and resident files for LPA to review as part of the inspection process and stated that the administrator has the key to the cabinets. This observation was identified during the annual inspection in 2024.

A review of (5) resident files was conducted and noted on the LIC 858.
A review of (2) staff files was conducted and noted on the LIC 859.

Emergency Drills were observed to be inadequate because the administrator was not able to provide documents that it was conducted accordingly.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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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Document Has Been Signed on 03/11/2025 05:22 PM - It Cannot Be Edited


Created By: Murial Han On 03/11/2025 at 11:19 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: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

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 2 out of 2 staff did not have proof that required annual training was completed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2025
Plan of Correction
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The administrator will provide a plan of correction to ensure staff training is completed and will provide a copy of the plan to CCL by 3/12/2025.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 observed medication cabinet and sharps were unlocked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2025
Plan of Correction
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The administrator will provide a plan of correction to ensure medication cabinet and sharps are locked and inaccessible to resident at all times and will provide a copy of the plan to CCL by 3/12/2025.
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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/11/2025 05:22 PM - It Cannot Be Edited


Created By: Murial Han On 03/11/2025 at 11:19 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: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(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
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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 emergency drills were completed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2025
Plan of Correction
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The administrator will provide a plan of correction to ensure emergency drills are completed and will provide a copy of the plan to CCL by 3/12/2025.
Type A
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

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 3 residents have bedrails without a physician's order which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2025
Plan of Correction
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The administrator will provide a plan of correction to ensure physician orders are obtained for the residents with bedrails and will provide a copy of the plan to CCL by 3/12/2025.
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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/11/2025 05:22 PM - It Cannot Be Edited


Created By: Murial Han On 03/11/2025 at 11:19 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: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

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 6 out of 6 residents did not have a reappraisal and/or an updated reappraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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The administrator will provide a plan of correction to ensure all residents have a reappraisal and/or an updated reappraisal and will provide a copy of the plan to CCL and a copy of the appraisals/reappraisal to CCL by 3/18/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


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Document Has Been Signed on 03/11/2025 05:22 PM - It Cannot Be Edited


Created By: Murial Han On 03/11/2025 at 11:42 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: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87755(c)
87755 Inspection Authority of the Licensing Agency


This requirement is not met as evidenced by: S2 was not able to provide staff and residents files for reveiw as the administrator has the key(s) to the file cabinets and the administrator was not on-site upon LPA's entrance.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above S2 was not able to provide staff and residents files for review as the administrator has the key(s) to the file cabinets and the administrator was not on-site upon LPA's entrance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2025
Plan of Correction
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The administrator will develop a plan to ensure compliance and will provide a copy of the plan of correction to CCL by 3/12/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: BURLINGAME SENIOR HOME 2
FACILITY NUMBER: 415600648
VISIT DATE: 03/11/2025
NARRATIVE
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During today's visit, an immediate civil penalty of $500 is being assess as LPA observed 3 repeat violations that were cited during the annual inspection in 2024 :87465(h)(2), 87755(c), and 1569.695(c).

The administrator will provide a copy of the liability insurance to CCL by 3/12/2025.

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 additional civil penalties.

This report is reviewed and discussed with the administrator; a copy of the report and appeal rights were provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC809 (FAS) - (06/04)
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