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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601126
Report Date: 01/15/2025
Date Signed: 01/15/2025 01:16:44 PM

Document Has Been Signed on 01/15/2025 01:16 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 LIVINGFACILITY NUMBER:
415601126
ADMINISTRATOR/
DIRECTOR:		IGNACIO LOPEZFACILITY TYPE:
740
ADDRESS:250 MYRTLE ROADTELEPHONE:
(650) 343-2747
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 90CENSUS: 58DATE:
01/15/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator, Ignacio LopezTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 1/15/2025, Licensing Program Analyst (LPA) Murial Han conduced an unannounced Case Management visit to follow - up on an Unlawful Detainer order. LPA met with the administrator and explained the purpose of today's visit.

Facility was granted an unlawful detainer order for residents #1 (R1) due to non-payment and according to the order, R1 was supposed to be discharged today.

Upon entrance, LPA observed the administrator, 3 sheriffs, 2 Ombudsman, representative from the placement agency and a administrator and a resident service coordinator from another facility assisting R1 with discharge planning.

After a few hours of working with R1, the administrator reported that the sheriffs did not remove R1 from the facility as R1 refused to leave and go to a destination that was arranged by the facility. Therefore, R1 will be staying for 5 more days while the placement agency is seeking for a safe discharge destination.

No deficiency cite today.

This report is reviewed and discussed with the administrator.

A copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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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