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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601126
Report Date: 07/08/2025
Date Signed: 07/08/2025 12:49:11 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
05/09/2025 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250509083556
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: 52DATE:
07/08/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Interim Administrator, Rowena CancinoTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Staff do not ensure carpeting is clean and sanitary
Staff do not ensure that facility is maintained at a comfortable temperature
Staff do not ensure facility vehicle is in good repair
Director does not have the required qualifications
Staff do not ensure elevators are in good repair
INVESTIGATION FINDINGS:
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On July 8, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the complaint investigation findings. LPA met with the interim administrator, Rowena Cancino and explained the purpose of today's visit.

Regrading to the allegations of- staff do not ensure carpeting is clean and sanitary, the reporting party stated that when resident #1 (R1) moved in on 3/21/2025, the carpet was filthy and smelled very bad resulting R1 being temporary placed in a different room.

As part of the investigation, LPA interviewed the interim administrator and the sales manager and both of them acknowledged that when R1's responsible party toured the facility, they have observed the carpet being dirty and it was supposed to be cleaned and renovated before the move-in date but it was not done and R1 had to be placed in a different room while the carpet was being replaced. The interim administrator stated that the carpet was replaced by Vinyl a few days later and R1 was moved into that room.

After the investigation, this allegation is deemed to be substantiated.





Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
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 7
Control Number 14-AS-20250509083556
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: 07/08/2025
NARRATIVE
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Regarding to the allegation of - staff do not ensure that facility is maintained a comfortable temperature, the reporting party stated, R1 was being placed in a temporary room, while the facility replaced the carpet but the heater was broken.

According to the sales manager and the interim administrator, the temporary room was vacant for a long time and no one checked the heater prior to R1's move-in as R1 was not supposed to move in to that room, therefore, the facility was not aware that the heater was not working. The interim administrator stated that they called a couple of companies to fix it but they couldn't so they provided a portable heater for R1.

LPA interviewed R1 who stated that the temperature of the room was comfortable after the portable heater was provided and LPA observed the room temperature was measured at 73 degrees Fahrenheit.

After the investigation, this allegation is deemed to be substantiated.

Regarding to the allegation of- staff do not ensure facility vehicle is in good repair, the reporting party stated the facility van has been broken for months and on 4/9/2025, R1 had a medical appointment and R1 had to be transported by the maintenance guy in a personal truck that required R1 to climb into.

According to the interim administrator, the facility van was broken on the day of R1's appointment but it has been fixed. The interim administrator stated that the facility provides transportation for residents on Tuesdays and Thursdays, and R1's appointment was on a Wednesday and since the van was broken, the maintenance manager took the resident to the appointment in a private vehicle. The interim administrator stated that she/he was not aware that R1 had to climb into the private vehicle until after the appointment. The interim administrator acknowledged that the facility van breaks down from time to time and when that happens, the facility offers other means of transportation such as vouchers to transportation companies.

LPA has completed and substantiated a complaint investigation in November 2024 (reference number 14- AS- 20241121125035) regarding to residents were missing their medical appointments because the facility van was broken.

After the investigation, this allegation is deemed to be substantiated.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 14-AS-20250509083556
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: 07/08/2025
NARRATIVE
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Regarding to the allegation of- director does not have the required qualifications, the reporting party stated that the interim director/administrator doesn't have the qualifications to be in the position.

According to the interim administrator who used to be the Health Services Director stated that when the Administrator resigned in February 2025, she was appointed by the Licensee to be the interim administrator.

Based on observation and record review, the licensee did not provided any documentation to CCL to update the facility administrator.

After the investigation, this allegation is deemed to be substantiated.

Regarding to the allegation of- staff do not ensure elevators are in good repair, the reporting party stated that on 5/5/2025, both facility elevators were broken and residents waited downstairs for over 3 hours until one of them was fixed.

As part of the investigation, LPA interviewed the sales manager and the interim administrator who acknowledged that both elevators were down on 5/5/2025 and the elevator on the right side has been down for almost 2 years. The sales manager was present on 5/5/2025 and stated that when they learned that the only working elevator was malfunctioned, they contacted management immediately, and call the elevator repair company. The sales manager acknowledged that there were a few residents who were not able to take the stairs so they waited for hours in the dining until the elevator was fixed.

LPA completed and substantiated a complaint investigation on 3/11/2025 (complaint reference number 14-AS-20250110144222) regarding to Licensee did not ensure facility elevators were maintained in good repair.

After the investigation, this allegation is deemed to be substantiated and a civil penalty of $250 is being assessed for repeat violation.

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 additional civil penalties.

Report was discussed with the interim administrator; a copy is provided with Appeal Rights.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
05/09/2025 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250509083556

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: 52DATE:
07/08/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Interim AdministratorTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Staff do not ensure the facility internet service is functioning
Staff do not ensure resident's showering needs are being met
Staff do not ensure resident's incontinence needs are being met
INVESTIGATION FINDINGS:
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On July 8, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the complaint investigation findings. LPA met with the interim administrator, Rowena Cancino and explained the purpose of today's visit.

Regarding to the allegation of- staff do not ensure the facility internet service is functioning, the reporting party stated that resident #1 (R1)'s responsible party was told that R1 would have WiFi in the room and then found out they don't have it in every room. The reporting party stated that the facility eventually fixed the issue.

As part of the investigation, LPA interviewed the interim administrator and R1.

The interim administrator stated that there is WiFi in every room but R1's room was toward the back and far away from the router. However, the interim administrator purchased a WiFi extender for the room and the problem was fixed.

LPA interviewed R1 who stated that there was WiFi in the room but it was slow and it was a lot better after the facility provided the extender.

After the investigation, this allegation is deemed to be unsubstantiated.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 14-AS-20250509083556
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: 07/08/2025
NARRATIVE
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Regarding to the allegation of - staff do not ensure resident's showering needs are being met and staff do not ensure resident's incontinence needs are being met, the reporting party stated that there is a resident on the first floor near the elevator that doesn't shower, and smells like urine. The reporting party stated that everyone knows who this resident is, and staff just say this resident doesn't like to shower.

As part of the investigation, LPA interviewed the interim administrator who stated that resident #2 (R2) has a history of refusing shower and did not allow facility staff to assist with incontinence care and cleaning the room but R2 is no longer refusing after many conversation of encouragement. The interim administrator reported that the odor is not as strong since R2 has been showering weekly, allowing staff to assist ADLs, and weekly housekeeping and laundry service.

LPA attempted to interview R2 but was not successful.

LPA interviewed staff #1 (S1) and staff #2 (S2) and both of them reported that R1 is no longer refusing care, R2 has been showering weekly, managing his/her own incontinence care, and allowing staff to assist with laundry and housekeeping services.

During LPA's visits on 5/14/2025, 7/3/2025 and 7/8/2025, LPA did not observed any odor by the entrance, by R2's room and the lobby area.

This observation was reported to CCL in 2024 and at the time, the facility has provided documentation to proof that the facility implemented different interventions to encourage R2 to participate in care.

After the investigation, this allegation is deemed to be unsubstantiated.

Based on observation, interviews and records review, these allegations are deemed to be unsubstantiated.

Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

This report is review with the interim administrator and a copy is provided

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 14-AS-20250509083556
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: 07/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/09/2025
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. This requirement is not met as evidenced by based on observation, and interview
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The Licensee will develop a plan to ensure the facility is clean, safe, sanitary and in good repair at all times; the plan shall indicate how the facility shall monitor the deficient areas, and it shall also include the time-frame for the elevator repair.
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R1 room's carpet was dirty, the heater was not working in, both elevators and the facility van were broken which poses an immediate health and safety risks to residents in care.
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 and it shall be signed by the Licensee as the facility currently does not have a designated administrator.
Type A
07/09/2025
Section Cited
CCR
87405(a)
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87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by the facility did not have a
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The licensee will develop a plan to ensure the facility has a qualified and current certified administrator and provide a copy of the plan of correction to CCL by 7/9/2025 and
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qualified administrator since March 2025 which poses an immediate health and safety risks to residents in care.
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it shall be signed by the Licensee as the facility currently does not have a designated administrator.
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: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 14-AS-20250509083556
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: 07/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2025
Section Cited
CCR
87303(b)
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87303 Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. This requirement is not met as evidenced by R1 was admitted to a room that was cold because
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The Licensee will develop a plan to ensure residents are residing in a environment with comfortable temperature. The Licensee will provide a copy of the plan to CCL by 7/16/2025 and it shall be
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the heater was malfunctioned which poses a potential health and safety risk to resident in care.
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signed by the Licensee as the facility currently does not have a designated administrator.
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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: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7