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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601126
Report Date: 11/13/2025
Date Signed: 11/13/2025 10:41:39 AM

Document Has Been Signed on 11/13/2025 10:41 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:BURLINGAME SENIOR LIVINGFACILITY NUMBER:
415601126
ADMINISTRATOR/
DIRECTOR:		ROWENA CANCINOFACILITY TYPE:
740
ADDRESS:250 MYRTLE ROADTELEPHONE:
(650) 343-2747
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 90CENSUS: 50DATE:
11/13/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:56 AM
MET WITH:Administrator, Brian RaimundoTIME VISIT/
INSPECTION COMPLETED:
10:50 AM
NARRATIVE
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On 11/13/2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to deliver the finding of an incident that was reported by the facility. LPA met with administrator, Brian Raimundo and explained the purpose of today's visit.

On 10/9/2025, the facility reported that staff #1 (S1) witnessed staff #2 (S2) and staff #3 (S3) holding resident #1 (R1)'s arms down in bed while forcing R1 to take medicine.

LPA attempted to interview R1 and R1 did not remember the incident and was not able to answer LPA's questions due to R1's diagnosis.

LPA interviewed S1 who stated that on the day of the incident, she was working on the Assisting Living Unit and was called to assist the Memory Care Unit. When she got off the elevator, she heard R1 screaming in the room and when she got to the room, she witnessed S2 and S3 were holding R1's arms while forcing R1 to take the medicine.

LPA interviewed S2 who stated that on the day of the incident, R1 did not want to take the medicine and R1 was attempting to hit S3 while S3 was trying to give the medicine so S2 assisted S3 by holding down R1's arms while R1 was in bed. S2 stated that R1 needed to take the medicine so R1 would not hit other people.

LPA requested to interview S3 but S3 did not return call.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 LIVING
FACILITY NUMBER: 415601126
VISIT DATE: 11/13/2025
NARRATIVE
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LPA interviewed the memory care director who stated that she was not at the facility when the incident happened but when she was informed on the next day, she reported it to the Regional Director of Operations and both staff were placed on administrative leave.

LPA interviewed the current administrator who stated that he was not the administrator when the incident happened but he was informed by the Regional staff that S2 and S3 were terminated.

Based on training records, the facility provided an in-service on 10/8/2025 on Medication Pass and the training material indicated that resident shall not be forced to take medication, but the staff sign-in record did not indicate that S3 attended the in-service.

After the investigation, this incident is substantiated as R1 has the Right to receive or reject medical care or other services.

Based on interviews, observation, and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation was determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed with administrator and a copy is provided with Appeal Rights.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/13/2025 10:41 AM - It Cannot Be Edited


Created By: Murial Han On 11/13/2025 at 09:59 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 LIVING
FACILITY NUMBER: 415601126

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/14/2025
Section Cited
CCR
87468.1(a)(16)

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87468.1Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16)To receive or reject medical care or other services.
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The administrator/ licensee will develop a plan of correction to indicate what was the facility's immediate action to ensure R1's safety. The plan shall also include what is the action that the facility will take to prevent this from
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This requirement has not been met as evidenced by based on observation, record review and interview, S1 witnessed R1 was screaming and yelling and S2 and S3 were holding R1's arms in bed while administering medicine which posed an immediate health and safety risk to resident in care.
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happen again. The plan shall include staff education. The administrator will provide a copy of the plan to CCL by 11/14/2025.
Type A
11/14/2025
Section Cited
CCR87411(a)

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87411 Personnel Requirements - General (a)Facility personnel shall at all times be.. and competent to provide the services necessary to meet resident needs. This requirement is not met as
evidenced by based on observation, interview and record
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The administrator/licensee will develop a plan of correction to ensure staff attends all required training. The plan shall include what is the monitoring process to ensure staff members are competent after the training. .
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review, the facility director provided an in-service on 10/8/2025 on Medication Pass that included residents shall not be forced to take medicine but S2 did not attend the in-service which posed an immediate health and safety risks to residents in care.
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The administrator/licensee will provide a copy of the plan of correction to CCL by 11/14/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2025


LIC809 (FAS) - (06/04)
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