Inspection visit

Incident investigationJune 29, 2023

BURLINGAME SENIOR LIVINGLicense 4156011265 citations on this visit

5 citations recorded

Inspector’s narrative

What the inspector wrote

On June 29, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that occurred on June 7, 2023. LPA met with Executive Director, Emaude (Alex) Tayebi and explained the purpose of the visit. The Licensee reported Resident 1 (R1) had an unwitnessed fall in his/her room. R1 was transported to the hospital and head injuries were noted. During the visit, LPA reviewed R1's file and interviewed the Administrator and Resident Services Director, Rowena Cancino. According to staff interviewed, R1 has had a total of three falls the past month (5/1/2023, 5/23/2023, and 6/7/2023). During record review, LPA discovered that incident reports for the incidents that occurred on 5/1/2023 and 5/23/2023 were not reported to CCLD. According to file reviewed, R1 has a diagnosis of Alzheimer's Dementia with behavioral disturbances. Based on R1's service plan, R1 is fall risk and has a wandering behavior. The service plan was dated 5/3/2023 after R1 had an unwitnessed fall and was taken to the hospital on 5/1/2023. R1 had two additional falls after the service plan was updated, however the facility failed to reassess R1 after the falls that occurred on 5/23/2023 and 6/7/2023. In addition, during record review, LPA observed the service plan to be incomplete as it was not be signed by R1's responsible party. During the record review, LPA observed Staff 1 (S1) and S2 to not be associated at the facility. LPA reviewed facility personnel records and observed S1 and S2 to have fingerprint clearance, however was not associated to the facility. Continue to 809C. LPA did not observed S1's and S2's criminal record clearance documentation in personnel files. Executive Director was able to provide LPA with proof from Guardian indicating staff are fingerprint cleared but not associated to the facility. A civil penalty of $200 is being assessed for S1 and S2 for not being associated to the facility. 87463(a) Reappraisal- A civil penalty of $250 is assessed on 6/29/2023 for a repeat violation within 12 months. This violation was cited on 6/6/2023. Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with Executive Director; a copy of the report is provided with appeal rights. Copy of civil penalty is provided.

Citations

5 citations recorded^*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

87211(a)(1)Type B
Report specified resident events within seven days
87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...Violation of this regulation is not met as evidenced by: Based on record review, the Licensee failed to submit two incident reports from 5/1/2023 and 5/23/2023 to CCLD.
87355(e)(2)Type A
Obtain required California clearance or exemption
87355 Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)..Violation of this regulation is not met as evidenced by: Based on record review, LPA observed S1 and S2 to have fingerprint clearance, however was not associated to the facility.
87412(a)(13)(B)Type A
Collect criminal clearance or exemption documentation
87412 Personnel Records: (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:(13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance:(B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).Violation of this regulation is not met as evidenced by: Based on record review of personnel files, LPA did not observe documentation of criminal record clearance for S1 and S2.
87463(a)Type B
Update reappraisal at required intervals
87463 Reappraisals: (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to...Violation of this regulation is not met as evidenced by: Based on file reviewed, the Licensee reassessed R1 after having an unwitnessed fall incident on 5/1/2023, however the facility failed to reassess R1 after having two additional unwitnessed falls on 5/23/2023 and 6/7/2023.
87506(a)Type B
Maintain separate complete record for each resident
87506 Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility...Violation of this regulation is not met as evidenced by: Based on file reviewed, LPA observed that R1's service plan was incomplete as it was not signed by R1's responsible party.

FAQ · About this visit

Common questions about this visit

What happened during the June 29, 2023 inspection of BURLINGAME SENIOR LIVING?

This was an other inspection of BURLINGAME SENIOR LIVING on June 29, 2023. 5 citations were issued: 2 Type A (serious) and 3 Type B.

Were any citations issued to BURLINGAME SENIOR LIVING on June 29, 2023?

Yes, 5 citations were issued (2 Type A, 3 Type B). The first citation was for: "87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may..."

What type of inspection was this?

This was an other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLD View original report

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Data from CCLD public records. Last updated June 15, 2026. If you believe any information is inaccurate, report it here.

Incident investigation·June 29, 2023