410508825-4-23-2026-14-AS-ACON-DTKSS4-20260428140716

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 410508825
Report Date: 04/17/2026
Date Signed: 04/23/2026 02:33:02 PM

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
02/11/2026 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20260211175444

FACILITY NAME:	BURLINGAME VILLA, INC.		FACILITY NUMBER:	410508825
ADMINISTRATOR:	MEDORIO, ANA		FACILITY TYPE:	740
ADDRESS:	1117 RHINETTE AVENUE		TELEPHONE:	(650) 344-7074
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY:	27	CENSUS: 25	DATE:	04/17/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator, Ana Medorio		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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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

INVESTIGATION FINDINGS:

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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

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026

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 4

Control Number 14-AS-20260211175444

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 VILLA, INC.	FACILITY NUMBER: 410508825
	VISIT DATE: 04/17/2026

NARRATIVE

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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.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 14-AS-20260211175444

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 VILLA, INC.	FACILITY NUMBER: 410508825
	VISIT DATE: 04/17/2026

NARRATIVE

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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.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 14-AS-20260211175444

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 VILLA, INC.	FACILITY NUMBER: 410508825
	VISIT DATE: 04/17/2026

NARRATIVE

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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.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026

LIC9099 (FAS) - (06/04)

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