Burlingame Villa, Inc.

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.

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.

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.

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.

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. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.

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. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.

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.

Page 2: LIC9099C - Investigation findings In regards to the medication not being administered as prescribed, it is discovered when medication administration record (MAR) were reviewed by LPA, the medication order and dosage are on record as well as on the MAR, showing medications were being administered per doctor's order. Upon admission there was a mis-communication to the resident's responsible party about the new medication order as the medication had increased in frequency. LPA did not find evidence of facility over medicating as the medication order is present and facility is administering accordingly. There was a change from PCP to the facility's normal physician they use due to the mis-communications between the PCP and facility physician which may have caused confusion as the facility had the facility physician assess and prescribe medications based on a virtual assessment. LPA could not prove or disprove any medication mismanagement. 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 at this time. No citation issued. Report is reviewed with administrator.

On this day at 1300hrs, Licensing Program Analyst (LPA) Jaime Vado and Kevin Varilla conducted an unannounced infection control annual inspection. LPA met with administrator Ana Medorio and explained purpose of today's inspection. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is observed as in place. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Facility ambient temperature is warm and comfortable, and lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped with grab bars and non-skid flooring material. Liquid soap is available. First-aid kit is inspected and is complete. A Disaster and Mass Casualty Plan is observed. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been finger print cleared and associated to the facility. Administrator certificate is viewed as current expiring 11/12/2023. Mitigation plan is reviewed with the administrator. It is current with no changes. LPA Vado reviewed the mitigation plan with the administrator and approved on this day. The following updated forms are requested to be submitted to CCLD by 06/29/2021 : • Administrator Certificate • LIC 308 Designation of Administrative Responsibility • LIC 500 Personnel Report • LIC 610E Emergency Disaster Plan No deficiencies cited today. Report is reviewed with administrator Ana.

On this day at 1330hrs, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management in conjunction with opening a 10 day initial complaint investigation visit. LPA met with administrator Ana Medorio and explained purpose of today's visit which was to make observations regarding the masking of staff. During today's visit LPA toured the facility independently and made observations on the ground floor and upper floor. LPA observed all staff wearing masks on this day. LPA observed at least six staff members wearing masks. Both floors observed all staff are wearing masks. LPA advised administrator to review the newest PIN regarding masking guidelines within the facility. She notified LPA that she conducted additional masking training on 08/05/21 and 08/06/21 regarding masking and posted additional masking reminders thorough out the facility. LPA did observe these masking signs during today's tour of the facility. No citations issued. Report is reviewed with administrator.

Licensing Program Analyst (LPA) Gladys Kuizon conducted an annual inspection today and met with Administrator Ana Medorio. At 1:05 PM, LPA entered the facility through the facility's central entry point and was screened by staff. At 1:30 PM, a tour of the facility was conducted. COVID-19 postings including hand-washing and infection control guides were observed throughout the facility including on the main entrance, hallways, staff break room and bathrooms. Staff were observed wearing face coverings. Residents were observed in their rooms and the facility's communal dining room with staff. The facility has at least 30 days' supply of personal protective equipment (PPE) including face shields, isolation gowns, gloves, and face masks. Disinfection supplies, hand sanitizers, soap, and paper supplies were observed available. At least 2 days' supply of perishable food and at least 1 week's supply on non-perishable food supply was observed in the premises. Per Administrator, the facility has reached over 80% vaccination rate against COVID-19 for both residents and staff. The facility is currently accepting visitors inside the facility. Screening procedures including sign-in and symptom checking is in place for all visitors and staff. Facility's contact information was verified current with Administrator. No deficiencies were cited. Exit interview conducted with Administrator and a copy of this report was provided during visit.