Inspection Reports for Burlingame Senior Living

An unannounced case management visit was conducted to follow up on an incident reported by the facility involving staff allegedly forcing a resident to take medicine.

The Licensing Program Analyst toured the Memory Care Unit, interviewed the resident and staff, and requested documents related to the incident and administrator submission. No deficiencies were cited during this visit.

An unannounced Case Management visit was conducted to follow-up on an incident reported by the facility involving a resident's unwitnessed fall and subsequent injury.

The resident was observed to be comfortable with no further falls reported. The facility has implemented status checks every 2 hours and physical therapy for the resident. No deficiencies were cited during this visit.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2025-05-09 regarding facility maintenance, staff qualifications, and resident care issues at Burlingame Senior Living Facility.

The investigation substantiated several allegations including unclean carpeting, malfunctioning heaters, broken elevators, a facility van in disrepair, and an unqualified interim administrator. Some allegations such as internet service issues and resident showering/incontinence care were found unsubstantiated.

The complaint investigation was substantiated based on evidence including interviews, observations, and record reviews. Allegations included unclean carpeting, broken heaters, broken elevators, unqualified administrator, and broken facility vehicle. Some allegations such as internet service and resident showering/incontinence care were unsubstantiated. A civil penalty of $250 was assessed for repeat elevator violation.

An unannounced Case Management visit was conducted to follow up on an incident reported by the facility regarding a resident who left the facility.

The resident who left the facility was found to be independent and able to leave unassisted. The facility issued a 30-day eviction notice due to non-payment and is assisting with discharge planning. No deficiencies were cited during the visit.

The visit was an unannounced office inspection conducted to evaluate the facility's compliance with licensing requirements.

The report does not provide specific findings or deficiencies; it includes general information about the licensing process, deficiency types, plans of correction, and appeal rights.

An unannounced complaint investigation was conducted in response to an allegation that the licensee did not ensure facility elevators were maintained in good repair.

The investigation substantiated that one of the two elevators had been malfunctioning for over a year, and the facility was unable to provide documentation proving repairs or replacement were in progress. This posed an immediate health and safety risk to residents, staff, and visitors.

The complaint was substantiated. The allegation was that the licensee did not ensure facility elevators were maintained in good repair. Evidence showed one elevator was broken for over a year, and the only working elevator malfunctioned intermittently, causing delays for residents, family members, and paramedics during emergencies.

The inspection visit was an unannounced continuation visit for an annual inspection conducted to review compliance with licensing regulations.

The inspection found multiple deficiencies related to staff criminal record clearances, annual training requirements, and personnel health screening documentation. Plans of correction were required to address these issues.

An unannounced Case Management visit was conducted to follow up on an Unlawful Detainer order related to a resident's non-payment and planned discharge.

The resident subject to the Unlawful Detainer order refused to leave the facility, resulting in a delay of discharge for five more days while a safe discharge destination is sought. No deficiencies were cited during this visit.

An unannounced complaint investigation was conducted due to allegations that staff did not ensure residents were transported to medical appointments because the facility van was broken and no alternative transportation arrangements were made.

The investigation found that residents were missing medical appointments and not scheduling new ones due to lack of transportation. Residents were unaware that the facility was offering Uber or Taxi rides as alternative transportation while the van was being repaired. The allegation was substantiated based on interviews and observations.

The complaint was substantiated. Residents reported missing appointments and not scheduling new ones due to lack of transportation. The facility van had been broken for over eight weeks and residents were not aware of alternative transportation arrangements such as Uber or Taxi rides offered by the facility.

The inspection was an unannounced complaint investigation visit conducted in response to allegations including a resident wandering from the facility due to lack of staff supervision and staff not safeguarding a resident's possessions.

The investigation substantiated that a resident (R1) wandered from a secured memory care unit unattended and was found outside the facility, with staff unaware how the resident exited. Another allegation regarding misplaced hearing aids was unsubstantiated as records showed the resident did not have hearing aids upon admission.

The complaint investigation was substantiated regarding a resident wandering from the facility due to lack of staff supervision. The allegation about staff not safeguarding resident's possessions was unsubstantiated.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2024-05-22 regarding resident care and staff conduct at Pacifica Senior Living Burlingame.

The investigation substantiated that the facility violated resident #1's privacy rights by sharing personal information with relatives without consent. Other allegations including rough handling, bullying, financial abuse, and preventing contact with the Ombudsman were found to be unfounded after interviews and record reviews.

The complaint investigation was substantiated for the allegation that staff did not accord resident privacy while in care, specifically sharing resident #1's personal information without consent. Other allegations including rough handling, bullying, financial abuse, and preventing contact with the Long Term Ombudsman were investigated and found to be unfounded.

An unannounced case management visit was conducted to follow-up on an incident reported by the facility involving a resident who left the facility unassisted contrary to physician's orders.

The facility failed to ensure care and supervision for a resident who left the facility unassisted despite a physician's order prohibiting this, posing an immediate health risk. A repeat violation was cited and a civil penalty of $250 was assessed.

An unannounced annual inspection was conducted to evaluate compliance with licensing requirements and facility standards.

The inspection found deficiencies related to inadequate CPR/First Aid certification among staff, unclean kitchen areas, and lack of documentation for emergency drills. Plans of correction were requested to address these issues.

An unannounced annual inspection was conducted by Licensing Program Analyst Murial Han to evaluate the facility's compliance with regulatory standards.

The inspection included a tour of the 4-story facility, review of emergency call systems, fire extinguisher servicing, water temperature checks, and secure storage of medications and chemicals. A review of four staff files was also conducted. The inspection was not completed and will be continued on another day.

The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-09-26 alleging that facility staff do not ensure resident records are properly maintained.

The investigation reviewed resident files and interviewed staff, finding some missing documents in one resident's file but overall the allegation was deemed unfounded as documentation was largely complete and the facility was working to update incomplete forms.

The complaint alleged that facility staff did not properly maintain resident records, including missing admission application documents and staff asking a reporting party to complete paperwork meant for physicians. The allegation was found to be unfounded after review of multiple resident files and interviews.

An unannounced case management visit was conducted in relation to a complaint investigation regarding the facility's failure to submit an incident report for a July 12, 2023 incident where a resident left the facility unassisted.

The facility failed to submit the required incident report for the July 12 incident and had a staff member who was not fingerprint cleared working during the visit. Civil penalties were assessed for both violations.

Complaint number 14-AS-20230714123226 triggered the investigation. The complaint was substantiated as the facility acknowledged failure to submit the incident report and had a staff member not fingerprint cleared.

An unannounced complaint investigation visit was conducted following a complaint received on 07/14/2023 regarding staff not preventing a resident from eloping.

The investigation substantiated that Resident 1, who has dementia and is unable to leave unassisted, left the facility unassisted multiple times, including on 07/12/2023. Staff did not accompany or redirect the resident despite the service plan indicating restrictions.

The complaint was substantiated. The allegation that staff did not prevent a resident from eloping was confirmed based on file review, staff interviews, and observations.

The visit was an unannounced plan of correction (POC) visit conducted to follow up on previous visits made on 6/29/23 and 7/10/23 to ensure the facility complied with citations issued on 6/29/2023.

The facility was assessed civil penalties for failing to provide a plan of correction for CCR 87211 Reporting Requirements. The plan of correction was received and verified on 7/10/2023, clearing the citation and stopping civil penalties.

An unannounced plan of correction (POC) visit was conducted to verify and confirm that the facility is in compliance with citations issued on 2023-06-29.

The facility was found to have corrected deficiencies related to personnel records, reappraisals, and resident records. However, the plan of correction for reporting requirements was not provided, resulting in a civil penalty assessment.

An unannounced case management visit was conducted to follow up on an incident involving Resident 1 who had an unwitnessed fall on June 7, 2023, with prior falls on 5/1/2023 and 5/23/2023. The visit aimed to review the incident and related facility compliance.

The facility failed to report two incident reports to the licensing agency, did not reassess Resident 1 after subsequent falls, and had an incomplete service plan not signed by the responsible party. Additionally, two staff members (S1 and S2) were fingerprint cleared but not associated with the facility, resulting in civil penalties.

The visit was complaint-related, following an incident involving Resident 1's unwitnessed fall on June 7, 2023. The complaint investigation found multiple deficiencies including failure to report incidents and reassess the resident, incomplete service plans, and staff association issues.

An unannounced case management visit was conducted to follow up on a death report submitted on May 11, 2023, regarding Resident 1 who passed away on May 10, 2023.

The facility failed to obtain a death certificate for Resident 1 and did not reassess the resident after a change in condition, nor develop an individualized needs and service plan to address the change. A deficiency was cited under the Residential Care Elderly California Code of Regulations, Title 22, Division 6.

An unannounced complaint investigation visit was conducted in response to multiple allegations received on 04/21/2023 regarding food quality, resident dignity, facility disrepair, and pest presence at Pacifica Senior Living Burlingame.

The investigation found no substantiated evidence supporting the allegations. The facility's food was deemed nutritious and appropriate, staff were not observed to treat residents without dignity, the facility was found to be in good repair, and no pests were observed or reported in recent inspections.

The complaint investigation was unsubstantiated. Allegations included staff not serving nutritious foods, staff not treating residents with dignity, facility disrepair, and presence of pests. Interviews, observations, and document reviews did not support these claims.

An unannounced complaint investigation visit was conducted in response to allegations received on 2023-03-23 regarding residents being left in soiled diapers, facility wall in disrepair, and staff not treating residents with dignity.

The investigation substantiated the allegations that residents were left in soiled diapers and that the facility wall was in disrepair, with a hole in the ceiling leaking water. The allegation that staff do not treat residents with dignity was unsubstantiated based on interviews with family members and staff.

The complaint investigation was substantiated for allegations that residents were left in soiled diapers and that the facility wall was in disrepair. The allegation that staff do not treat residents with dignity was unsubstantiated.

An unannounced case management visit was conducted to follow up on a death report submitted on April 6, 2023, regarding a resident who passed away on March 21, 2023.

The facility failed to report the resident's death within the required seven days as mandated by CCR 87211 Reporting Requirements. The death report was submitted to the licensing agency on April 6, 2023, well beyond the seven-day timeframe.

The visit was a prelicensing inspection to follow up on initial pre-licensing inspections conducted on 7/1/22 and 8/19/22, to verify corrections and readiness for licensure.

All previously noted deficiencies from prior visits were corrected, including updates to the Emergency Disaster Plan, signage identification, waste container lids, laundry machine operability, posting of visitation policy and admission agreement, and staff training on chain of command. Immediate licensure was recommended pending final review.

This was a pre-licensing unannounced visit to follow up on the initial pre-licensing inspection conducted on 7/1/22, to verify corrections and updates prior to licensure.

Several items from the initial inspection on 7/1/22 were reviewed, including updates to the Emergency Disaster Plan, signage for cage #4 in the garage, waste container lids in the kitchen, operability of the 3rd floor laundry machine, posting of the visiting policy, and administrator designee presence. Some items were addressed, while others were pending confirmation.

The visit was a prelicensing inspection for Pacifica Senior Living Burlingame as the applicant applied for RCFE licensure for 90 non-ambulatory elderly persons.

The facility was toured and found to have appropriate secured medication and toxin storage, emergency call systems, and food preparation areas. However, the Emergency Disaster Plan requires updating and fire extinguisher locations must be added. Additionally, the door to a memory care room occupied by a COVID resident was found open and not identified as an isolation room, which was discussed with the administrator. A follow-up visit is necessary due to time constraints.

The visit was an office evaluation conducted via telephone to complete Component II (COMP II) of the licensing process, verifying the applicant and administrator's understanding of Title 22 and related facility operation requirements.

The Component II evaluation was successfully completed with confirmation of understanding in areas including facility operation, staff qualifications, program policies, grievance procedures, and physical plant requirements. No deficiencies or violations were noted in the report.

The visit was conducted as a complaint investigation to the facility, which was observed to be advertising itself as a licensed RCFE without having an approved or granted license.

The facility was found to be advertising and doing business as a licensed RCFE without having a valid RCFE license, which poses a potential health, safety, or personal rights risk to clients in care.

The complaint investigation found that the facility was advertising as a licensed RCFE without having an approved or granted license, which is a violation of California Code of Regulations, Title 22.