Burlingame Villa

Type of visit: Required - 1 Year

On April 23, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA was met with the administrator, Ana and LPA explained the purpose of the visit. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Comfortable temperature is maintained and lighting is sufficient for comfort. This is a two story facility. On the 1st floor, there are 10 resident private rooms with their own bathrooms, one common bath/shower room, dining/activity room, and linen room. On the 2nd floor, there are 14 resident rooms(shared and private rooms), 5 shower/bathrooms in the hallways, staff lounge, and housekeeping room. LPA observed the bathrooms and showers are equipped with paper towels, soap, grab bars, and non-skid mats. Hot water temperature in the common shower room/bathroom and resident's room was measured at 123- 125 degrees F. 2 days for perishables and & 7 days non-perishable food were observed to be present. Facility is equipped with call system in the resident rooms, resident bathrooms, common shower rooms and common bathrooms. Fire extinguishers were last inspected on 3/24/2026, Fire drill records were reviewed to be adequate. A review of (5) facility resident records was conducted. A review of (3) facility staff records was conducted. Medications, chemicals and toxic were observed to be locked and inaccessible to residents in care. Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 23, 2026

Allegation investigated: Staff did not ensure resident's needs were met in a timely manner Staff interfered with resident visits Staff conduct poses a risk to residents in care Staff are not adequately trained

On April 23, 2026, Licensing Program Analyst (LPA) Murial Han conduct a visit to delivery the complaint investigation findings. LPA met with Administrator and LPA explained the purpose to today's visit. Regarding allegation of - staff did not ensure that resident’s needs were met in a timely fashion, there was no additional information forthcoming from the reporting party. However, during the initial reporting, the reporting party stated that on February 7, 2026, a family member was visiting resident #1 (R1) and noticed resident # 2 (R2) was in excruciating pain and no staff was around. In addition, the reporting party stated that the same family member went back to visit on the next day (February 8, 2026) and noticed R1 could not breathe and staff did not administer breathing treatment and oxygen as requested by the family member. As part of the investigation, LPA interviewed facility staff, R1’s responsible party and R2’s family member, R2, attempting to interview R1, and reviewed documentation. Unsubstantiated According to staff #1 (S1), on February 7, 2026, at approximately 11-12pm, while she was assisting residents on the 2nd floor, she got a call from staff informing her that R1’s family member was looking for her on the 1st floor. When S1 got to the 1st floor, R1’s family member informed her that R2 was in a lot of pain. S1 went to assess R2 who verbalized that he/she was fine and did not have any pain. Subsequently, S1 observed R2 showed some physical changes while eating lunch in the dining room which prompted S1 to reassess R2’s pain level and administered pain medication as R2 stated that he/she was in pain. Regarding the oxygen and breathing treatment, S1 stated that on February 8, 2026, R1’s family member requested to administer breathing treatment and oxygen for R1. S1 assessed R1 and did not observe R1 was having difficulty breathing but the family member requested it so S1 attempted to do it. However, R1 became resistive and was refusing the treatments so S1 stopped. On 2/20/26, LPA observed R1 and R2 were in their rooms and both residents appeared comfortable. R2 stated that he/she was not in pain. Based on documentation, the medication records indicate that on the day of the incident, R2 received pain medications in the morning and as needed pain medication at noon time. After the investigation, this allegation is deemed to be unsubstantiated as S1 attempted to administer oxygen and breathing treatment for R1 but R1 became resistive and did not want the treatment so S1 stopped. Regarding the pain medication, R2 got the routine pain medication during the morning shift at 7-10 am, and at around noon time when R1 was observed to have pain. Regarding the allegations of- staff interfered with resident visits and staff conduct poses a risk to residents in care, there was no additional information forthcoming from the reporting party. However, during the initial reporting, the reporting party stated that R1’s family member was told by S1 that he/she did not have the right to go to the 2nd floor because his/her loved one resided on the 1st floor. In addition, the reporting party stated that the family member reported that S1 was screaming, unhinged loud obnoxious inappropriate voice, very angry and told the family member that it was none of his/her business that R2 was in pain. As part of the investigation, LPA interviewed staff members, R1 and R2’s family members. LPA interviewed S1 who denied the allegation and stated that R1’s family member requested to give R1 oxygen and breathing treatment even though R1 did not appeared to be having difficult of breathing but S1 attempted to do it, however, R1 became agitated and resistive so she stopped. LPA interviewed S2 and S3 who were working on the day of the incident, and they did not observe S1 telling anyone that they were not allowed on the 2nd floor and other inappropriate behavior. LPA interviewed 5 residents who were in the dining room during the incident on February 7, 2026 and all of them did not recall the incident. After the investigation, this allegation is deemed to be unsubstantiated. Regarding to the allegation of – staff are not adequately trained, there was no additional information forthcoming from the reporting party. However, during the initial reporting, the reporting party stated that on February 8, 2026, R1’s family member requested S1 to administer breathing treatment and oxygen to R1 but S1 had no idea what she was doing. As part of the investigation, LPA interviewed the administrator, S1, staff #4 (S4) and reviewed documentation. The administrator denied the allegation and stated that S1 was trained by hospice on oxygen and nebulizer machines. The administrator stated that the training included setting up the machine, using the machine, and benefits from oxygen. LPA interviewed S1 who stated that she was trained on oxygen and breathing treatment and she attempted to administer it but R1 became resistive so she did not continue. LPA interviewed S4 who stated that they were trained in oxygen and breathing treatment administration and they also called the hospice nurse and obtained instructions on oxygen administration. Based on documentation provided, it revealed that S1 was training on 10/24/2024 by the hospice agency on oxygen and nebulizer administration. After the investigation, this allegation is deemed to be unsubstantiated. Based on these observations, and interviews the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated. The report is reviewed and discussed with the administrator. A copy is provided.the state’s words, verbatim · CDSS document, Apr 17, 2026 · control 14-AS-20260211175444

Type of visit: Case Management - Incident

On January 6, 2026, Licensing Program Analyst (LPA) Murial Han conducted a Case Management visit to follow-up on an incident that was reported by the facility. LPA met with the administrator and explained the purpose of today's visit. On December 23, 2025, the facility report an incident that happened on December 14, 2025 concerning resident #1 (R1) who appeared to be choking while eating in the dining room. Sequently, staff performed Heimlich Maneuver and called 911. When the paramedics arrived, R1 appeared to be back to baseline and R1 was not transferred to the hospital. During today's visit, the administrator stated that R1's physician and responsible party were notified of the incident. The administrator stated that the physician changed R1's diet to mechanical soft with small bites and ordered speech therapy and swallowing assessment test. The administrator stated that the facility has followed the physician's order and changed R1's diet and the responsible party will arrange for the swallowing assessment test and speech therapy. During today's LPA interviewed the kitchen staff who was able to report that they were serving R1 mechanical soft diet with small bites. LPA observed R1 eating lunch in the dining and the administrator confirmed that the consistency of the lunch was mechanical soft diet. No deficiency is cited today. This report is reviewed and discussed with the administrator. A copy is provided.the state’s words, verbatim · CDSS document, Jan 6, 2026

Type of visit: Case Management - Incident

On January 6, 2026, Licensing Program Analyst (LPA) Murial Han conducted a Case Management visit to follow up on an incident that was reported by the facility. LPA met with the administrator and explained the purpose of today's visit. On December 15, 2025, the facility reported an incident that happened on December 12, 2025, concerning resident 1 (R1) who was complaining of having back pain and was diagnosed with compression fracture in the spine at the hospital. R1 returned to the facility on the same day. During today's visit, LPA observed R1 in the room on a recliner sofa and appeared to be comfortable. R1 did not remember going to the hospital but stated that he/she was comfortable and did not have any pain. R1 stated that everyone at the facility took well care of him/her. Based on the hospital records, R1 has a diagnosis that could have contributed to the compression fracture. LPA interviewed the administrator who stated that there were no incidents that happened in which could have resulted in the injury. The administrator stated that R1 is doing well and is being seen by the home health team. No deficiency is cited today. This report is reviewed and discussed with the administrator. A copy is provided.the state’s words, verbatim · CDSS document, Jan 6, 2026

Type of visit: Case Management - Incident

On 11/13/2025, Licensing Program Analyst (LPA) conducted an unannounced case management visit to follow- up on an incident that was reported by the facility. LPA met with Resident Coordinator, Madeline Tigno and explained the purpose of today's visit. On 11/10/2025, CCL received an unusual incident/injury report from the facility reporting an incident that occurred on 11/6/2025 in which staff #1 (S1) gave resident #1 (R1) medication that was intended for resident #2 (R2). During today visit, LPA interviewed S1 who stated that when she returned from her lunch break, R1 usually sits in the dining room so she would give R1 medication. However, on the day of the incident, she noticed R1 was not in the dining room so she asked staff to get R1 to the dining room while preparing medication for R2. When she was about to give R2's medication to R2, R1 came into the dining room and she got distracted so she gave R2's medication to R1. S1 acknowledged that she did not ensure it was the Right Resident and the Right Medication prior to giving the medication to R1. Based on training records, S1 was trained in September 2023, September 2024 and on 11/6/2025 on Medications/ Medication Errors/Narcotics and S1 stated that the training covered " The Six Rights" of medication administration. Based on interview, records review and observation, deficient is cite for this incident because the S1 was trained on " The Six Rights" of Medication Administration, however, it was not followed while giving medication to R1 resulting in R1 received medication that was intended for R2. Based on observation, record review, and interviews deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with the Resident Coordinator; A copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Nov 13, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Nov 14, 2025

87411 Personnel Requirements - General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirment is not met as evidenced by while giving medication, S1 did not ensure it was right the medicaiton and the right resident which resulted in R1 who was giving medication that was intended for R2 which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: The administrator/licensee shall develop a plan to ensure the facility has a process to monitor the competency of staff members with medication administration after training. The administrator/ licensee will provide a copy of the plan to CCL by 11/14/2025.

Allegation investigated: Staff do not prevent private caregiver from inappropriately speaking to residents Staff do not prevent private caregiver from interfering with residents' activities

On June 18, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to delivery the complaint investigation findings. LPA met with the administrator and explained the purpose of today's visit. Regarding to the allegation of- staff do not prevent private caregiver from inappropriately speaking to residents, the reporting party stated that the facility has a private caregiver from a home care agency who yells at other residents and one day, a facility caregiver was trying to encourage a resident to take a shower, this private caregiver interfered, yelled at the resident and tried to force the resident to take a shower. The reporting party stated that most of the residents at the facility suffers from Dementia with some sort of behaviors including his/her loved one so he/she did want this private caregiver to yell at his/her loved one. As part of the investigation, LPA interviewed the administrator, the staff members, and the responsible party who hired the private caregiver. Unsubstantiated According to the administrator, she has never observed the private caregiver speaking inappropriately to residents and staff and no one has brought it to her attention as well. The administrator also stated that the responsible party who hired the private caregiver visited the resident almost daily and is very satisfied with the services that the private caregiver is providing. According to the person who hired the private caregiver, he/she stated that they visited the resident almost daily and has not witnessed any inappropriateness from the private caregiver to the residents. They also stated that they trust the private caregiver and they have worked with this person for many years. According to the facility staff, they have not witnessed the private caregiver speaking inappropriately to the residents and they reported that there was one time the private caregiver attempted to assist them with calming down a resident who was yelling and screaming but he/she was not rude and/or disrespectful to the resident. After the investigation, this allegation is deemed to be unsubstantiated. Regarding to the allegation of - staff do not prevent private caregiver from interfering with residents' activities, the reporting party stated the private caregiver takes the television remote, turns off the television and hides the remote, resulting in residents not able to watch television as an activity. As part of the investigation, LPA interviewed the administrator and the facility staff. The administrator denied the allegation and stated that she has not observed this behavior from the private caregiver nor it was reported to her. LPA interviewed the facility staff from different shifts and all of them stated that they have not witnessed such behavior from the private caregiver. Based on these observations, and interviews the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated. The report is reviewed and discussed with the administrator. A copy is provided.the state’s words, verbatim · CDSS document, Jun 18, 2025 · control 14-AS-20250429102905

Type of visit: Required - 1 Year

On May 5, 2025 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA was met with the administrator, Ana and LPA explained the purpose of the visit. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Comfortable temperature is maintained and lighting is sufficient for comfort. LPA observed residents were participating in activities in the dining room. This is a two story facility. On the 1st floor, there are 10 resident private rooms with their own bathrooms, one common bath/shower room, dining/activity room, and linen room. On the 2nd floor, there are 14 resident rooms(shared and private rooms), 5 shower/bathrooms in the hallways, staff lounge, and housekeeping room. LPA observed the bathrooms and showers are equipped with paper towels, soap, grab bars, and non-skid mats. Hot water temperatures were measured at 107- 110 degrees F. 2 days for perishables and & 7 days non-perishable food were observed to be present. Facility is equipped with call system in the resident rooms, resident bathrooms, common shower rooms and common bathrooms. Fire extinguishers were last inspected on 4/26/2025, Fire drill records were reviewed to be adequate. A review of (5) facility resident records was conducted. A review of (5) facility staff records was conducted. Medications, chemicals and toxic were observed to be locked and inaccessible to residents in care. No deficiency cited today; a copy is provided.the state’s words, verbatim · CDSS document, May 5, 2025

Allegation investigated: Facility personnel are not sufficient in numbers to meet residents' needs. Facility staff failed to observe resident for physical changes. Facility staff failed to seek timely medical attention for resident. Facility failed to follow infection control plan.

On October 9, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced complaint investigation visit to deliver the findings. LPA met with the administrator and explained the purpose of today's visit. Regarding to the allegation of- facility personnel are not sufficient in numbers to meet residents' needs, the reporting party stated the facility did not have sufficient staff to care for resident #1 (R1) because during a visit in October 2023, the reporting party observed R1 looked and smelled bad and they can not find anyone to work at the facility. As part of the investigation, LPA observed R1, interviewed the administrator, R1's responsible party and R1's family member. During the visit on 8/27/2024, LPA observed R1 who was in the room with a family member and R1 appeared with bright affect, cleaned, and well- groomed. Unsubstantiated LPA interviewed the administrator who denied the allegation and stated that the facility has sufficient staff to care for the residents and the facility just hired several new staff members. In addition, the administrator stated that she has good communication with R1's responsible party and this allegation was not brought up by the responsible party who visited R1 on a regular basis. LPA interviewed R1's responsible party who stated that for the most part, the facility has sufficient staff to care for R1 but there were times when R1 had to wait a little longer for assistance as the staff was busy with other residents. LPA interviewed R1's family member who visited R1 regularly and stated that this facility is the best place for R1 and he/she has not observed R1 to have unpleasant odor and/or unkempt during the visits. After the investigation, this allegation is deemed to be unsubstantiated. Regarding to the allegation of- facility staff failed to observe resident for physical changes, the reporting party stated that during a visit in Oct 2023, R1 had black and blue bruises all over R1's face. As part of the investigation, LPA interviewed the responsible party, the family member, and reviewed documents. According to R1's responsible party and a family member, the facility was aware of the black and blue bruises on R1's face because in Oct 2023, they were notified by the facility that R1 had an accident which resulted black and blue bruises on R1's face. They stated that after the accident, the facility implemented safety measures to ensure R1's safety. Based on the documents provided by the facility, there was an incident report completed by the facility in Oct 2023 reporting R1's accident and the report indicated that it was reported to the responsible party. After the investigation, this allegation is deemed to be unsubstantiated. Regarding to the allegation of- facility staff failed to seek timely medical attention for resident, the reporting party stated that during a visit in Oct 2023, he/she noticed R1 had classic signs of Urinary Tract Infection (UTI) and the facility did not notice it. As part of the investigation, LPA interviewed the administrator and R1's responsible party. According to the Administrator, R1 has recurrent UTI and R1 is on a routine medication for it. The administrator stated that when the facility was notified by R1's responsible party that R1 may have UTI, the facility took action right away and R1 was prescribed a medication for UTI. LPA interviewed R1's responsible party who validated the information that was provided by the administrator and stated that the facility did seek for medical attention right away when they were notified that R1 may have UTI. In addition, the responsible party stated the facility has always kept him/her in the loop of communication with R1's condition. After the investigation, this allegation is deemed to be unsubstantiated. Regarding to the allegation of - facility failed to follow infection control plan, the reporting party stated that R1 had COVID-19 but there was no signs, and no PPE supplies indicating that R1 had COVID-19. As part of the investigation, LPA toured the facility, interviewed the administrator, R1's responsible party, and R1's family member. During the visit on 8/27/2024, LPA observed a sign by the door alerting visitors of facility's COVID-19 status but LPA did not observe any PPE supplies set-up inside the facility. The administrator stated that PPE isolation carts were removed after everyone tested negative, however, they were placed in the hallway during outbreak. During the tour, LPA also observed facility has adequate PPE supplies. LPA interviwed R1's responsible party and R1's family member and they stated that the facility have adequate PPE supplies during the outbreak and there was a sign on the door informing the visitors. The responsible party stated that the facility informed him/her that R1 tested positive for COVID-19 and he/she informed the people who visited R1 on a regular basis. After the investigation, this allegation is deemed to be unsubstantiated. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated. The report is reviewed and discussed with the administrator. A copy is provided.the state’s words, verbatim · CDSS document, Oct 9, 2024 · control 14-AS-20240820082442

Type of visit: Case Management - Incident

On October 9, 2024, Licensing Program Analyst (LPA) Murial Han conducted a Case Management visit to follow-up on two incidents that were reported by the facility. LPA met with the administrator and explained the purpose of today's visit. On September 19, 2024 , the facility reported an incident that happened on 9/ 17/2024 that resident #1(R1) received medication that was intended for another resident. On October 7, 2024, the facility reported an incident that happened on 10/06/2024 that resident #2 (R2) received both AM and PM medications during the AM shift. During today's visit, LPA interviewed the administrator, the resident care coordinator, staff members and reviewed training records. In regards to the incident that happened on 9/17/2024, the resident care coordinator stated that the shift manager/ Medication Technician (S1) placed R1's medication in R1's food and a caregiver (S2) mistakenly feed another resident's food that also consisted of medication. According to S2, on the day of the incident, S2 was orienting a new staff who started to feed R1 and when S2 discovered that there was medication in the dessert, S2 instructed the new staff to stop feeding and immediately reported it to S1 which resulted S1 realizing that R1 was given another resident's medication. In addition, S2 stated that they have not observed medication in resident's food in the past, and this incident was the first time that they discovered medication in resident's food. According to the administrator and resident care coordinator, S1 made a mistake and it was corrected immediately. They also stated that the caregivers were not suppose to administer medication as they were not trained. LPA interviewed 4 caregivers and all of them reported that they do not give medication to residents, the shift managers do. After the incident, the facility completed a change of condition for R1 which consisted of reporting it to R1's provider, responsible party, CCL and Ombudsman. The facility monitored R1 and there was no adverse reaction noted. In regards to the incident that happened on 10/6/2024, the administrator stated that the shift manager/med tech (S3) made a medication error by administering R2's AM and PM medications on the AM shift. After the incident, the facility completed a change of condition for R2 that consisted of reporting it to R2's provider, responsible party, CCL and Ombudsman. The facility monitored R2 and there was no adverse reaction noted. Based on the training records provided by the facility, LPA observed the annual training was completed by the shift managers and training was conducted after the incident that happened on 9/17/2024. In addition, the administrator reported that the facility will have another training provided by an outside consultant company to ensure shift managers/med techs are educated on medication administration. No deficiency cited today. This report is reviewed and discussed with the administrator and a copy is provided.the state’s words, verbatim · CDSS document, Oct 9, 2024

Type of visit: Required - 1 Year

On May 2, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA was met with the administrator, Ana and LPA explained the purpose of the visit. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Comfortable temperature is maintained and lighting is sufficient for comfort. This is a two story facility. On the 1st floor, there are 10 resident private rooms with their own bathrooms, one common bath/shower room, dining area, and linen room. On the 2nd floor, there are 14 resident room(shared and private rooms) but the rooms do not have their own bathrooms; the bathrooms and showers rooms are located in the common area, there is also a dining room, staff lounge, and the housekeeping room. LPA observed the bathrooms and showers are equipped with paper towels, soap, grab bars, and non-skid mats. Hot water temperatures were measured at 105- 108 degrees F. 2 days for perishables and & 7 days non-perishable food were observed to be present. Facility is equipped with call system in the resident rooms, resident bathrooms, common shower rooms and common bathrooms. Fire extinguishers were last inspected on 5/30/2023, Fire drill records were reviewed to be adequate. A review of (5) facility resident records was conducted. A review of (5) facility staff records was conducted. Medications, chemicals and toxic were observed to be locked and inaccessible to residents in care. No deficiency cited today; a copy is provided.the state’s words, verbatim · CDSS document, May 2, 2024