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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601126
Report Date: 03/11/2025
Date Signed: 03/11/2025 01:13:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/10/2025 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250110144222
FACILITY NAME:BURLINGAME SENIOR LIVINGFACILITY NUMBER:
415601126
ADMINISTRATOR:IGNACIO LOPEZFACILITY TYPE:
740
ADDRESS:250 MYRTLE ROADTELEPHONE:
(650) 343-2747
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:90CENSUS: 50DATE:
03/11/2025
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Interim Administrator, Rowena CancinoTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Licensee did not ensure facility elevators were maintained in good repair
INVESTIGATION FINDINGS:
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On March 11, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the investigation findings. LPA met with the interim Administrator, Rowena Cancino and explained the purpose of today’s visit.

Regarding to the allegation of- Licensee did not ensure facility elevators were maintained in good repair, the reporting party stated that the facility has 2 elevators and over the last 2 years at any given time, at least one of them has not been working. Reporting party stated that their family member has witnessed during their recent visit that both elevators were malfunctioned during an emergency situation and the Emergency Medical Team had to wait 25 minutes for the staff to “re-set” the only working elevator.

As part of the investigation, LPA conducted observation, interviewed the pervious administrator, the resident coordinator director, and facility staff.


Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 14-AS-20250110144222
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/11/2025
NARRATIVE
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 According to the previous Administrator and the Resident Service Director, one of the elevators has been broken for more than a year and it was repaired but continued to break. The former Administrator denied the allegation that the paramedics were waiting for 25 minutes while responding to an emergency call and stated that if both elevators were down, the staff would direct the paramedics to use the stairs. The Resident Service Director stated that there was one time when both elevators were down, and the paramedics had to transport a resident to the room using the stairs.

The former Administrator and the Resident Service Director stated that the most recent visit from an elevator company informed them that the elevator needed to be replaced and the Senior Vice President has already approved it.

LPA interviewed staff #1 (S1) and staff #2 (S2) and both stated that one of the elevators has been broken for almost a year. They stated that the only working elevator would be down from time to time due to over usage. They stated that they were informed by other staff members that during Christmas Eve, the only working elevator was also down and residents, family members, and paramedics had to wait for a long time.

After the investigation, this allegation is deemed to be substantiated as the former administrator, the resident service director, and the facility staff reported that the elevator has been malfunctioned for over a year and the facility was not able to provide documents to proof that repairs were in progress. In addition, facility staff reported that when the only working elevator became malfunctioned, it created a big problem for the residents, facility staff, family members, medical visitors, etc.

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 the interim Administrator; a copy is provided with Appeal Rights 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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 14-AS-20250110144222
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/12/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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The Licensee and/or the administrator will provide a plan indicating details/actions that the facility will take to either repair or to replace the elevator. The plan shall have estimated time-frame of completion.
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This requirement is not met as evidenced by one of the two facility elevators has been malfunctioned for more than a year and the facility was not able to provide documents to proof that the repair or replacement of the elevator is in progress which poses an immediately health and safety risk to residents in care.
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The Licensee and/or the administrator will provide a copy of the plan to CCL by 3/12/2025.
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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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3