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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601126
Report Date: 08/20/2025
Date Signed: 08/20/2025 11:57:50 AM

Unsubstantiated


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
06/30/2025 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250630085851
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: 51DATE:
08/20/2025
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Administrator, Rowena CancinoTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff caused injury to resident in care.
INVESTIGATION FINDINGS:
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On 8/20/2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the complaint investigation finding. LPA met with the administrator and explained the purpose to today's visit.

Regarding to the allegation of- staff caused injury to resident in care, the reporting party stated that resident #1 (R1) with history of dementia and Alzheimer's with significant avulsion of left hand. Skin was avulsed from wrist to knuckles on top of hand, as if pulled down, full thickness, exposing connective tissue and vasculature of hand. When R1 was asked how the injury occurred, R1 stated staff “pulled on his/her arm” with no additional details.

As part of the investigation, LPA interviewed R1, facility staff, the administrator, R1's responsible party, and reviewed documents.

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

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
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-20250630085851
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: 08/20/2025
NARRATIVE
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According to the administrator, on the day of the incident, staff #1 (S1) was conducting morning routine rounds to check on the residents, and when S1 opened R1’s door, S1 witnessed R1 sitting by the end of the bed and holding the mattress pump (a device that keeps the mattress inflated). S1 proceeded to check on R1 and observed a wound on the left hand that was bleeding so S1 removed the device and called for assistance. Staff #2/med tech (S2) responded and arrived to assist. The administrator stated that after S2 saw the wound, they decided to call 911. R1 was transferred to the hospital and returned within 24 hours.

The administrator stated that the mattress pump was placed by the foot board of the bed but no one knew how R1 got hold of it. The administrator stated that since the incident, they have removed the mattress pump from the foot of the bed and place it on the floor to prevent this from happening again.

LPA interviewed R1 who stated that he/she can’t remember what happened to the hand, but maybe hit it on the door.

LPA interviewed S1 who denied pulling R1’s hand and stated that when she saw R1 was holding the mattress pump, R1’s left hand was bleeding so she removed the mattress pump, provided a pad to cover the wound and called for assistance.

LPA interviewed S2 stated that he did not pulling R1’s hand. S2 stated that when S1 called for assistance, he went to the room immediately and saw R1’s hand was bleeding, and it was covered with a pad. Therefore, they decided to call 911.

Both S1 and S2 stayed with R1 until the paramedics arrived and they did not witness anyone pulled R1's hand/arm.

LPA interviewed R1’s responsible party who stated that no one witnessed exactly what caused the skin tear and they are happy with the overall care that the facility is providing to R1 but the communication can improve at times.

During LPA’s visit on 7/3/2025, LPA observed R1 to be calm and left hand was wrapped with gauze. LPA observed the mattress pump was placed away from the foot of the bed.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 14-AS-20250630085851
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: 08/20/2025
NARRATIVE
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Based on the police report, it indicated that R1's injury appeared to have been accidental, and there is no merit to any elder abuse or neglect.

Based on interview, observation and record review during the course of the investigation, this allegation is deemed to be unsubstantiated.

Although the above investigations 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 reviewed and discussed with the administrator; a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3