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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600648
Report Date: 09/04/2025
Date Signed: 09/04/2025 12:27:53 PM

Substantiated


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
08/26/2025 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250826095648
FACILITY NAME:BURLINGAME SENIOR HOME 2FACILITY NUMBER:
415600648
ADMINISTRATOR:EHSANIPOUR, FERESHTEHFACILITY TYPE:
740
ADDRESS:1738 QUESADA WAYTELEPHONE:
(650) 692-1838
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:6CENSUS: 4DATE:
09/04/2025
UNANNOUNCEDTIME BEGAN:
11:28 AM
MET WITH:Caregiver, Ligaya MunozTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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The facility does not ensure the medication is safely stored
INVESTIGATION FINDINGS:
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On September 4, 2025, Licensing Program Analyst (LPA) Murial Han conducted a 10-day complaint visit. Upon entry, LPA met with caregiver, Ligaya Munoz, and LPA explained the purpose of today's visit. The administrator, Fereshteh Ehsanipour arrived shortly thereafter and assisted with the visit.

Regarding to the allegation of - the facility does not ensure medication is safely stored, there is no additional details provided by the reporting party.

During today's visit, LPA observed medication cabinet was not locked, and there were multiple bottles of medication placed outside of the medication cabinet. LPA observed some medications were stored on top of the medication cabinet and some were stored on a wooden file cabinet next the medication cabinet.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
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 5
Control Number 14-AS-20250826095648
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 SENIOR HOME 2
FACILITY NUMBER: 415600648
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/05/2025
Section Cited
CCR
87465(h)(2)
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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons....
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During the visit, the administrator has locked all the medication in a locked closet. The administrator will submit a plan of correction to CCL by 9/6/2025 and the plan will indicate that the facility will purchase a new medication cabinet to ensure compliance. The plan will also indicate the estimated date of arrival for the new cabinet.
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This requirement is not met as evidenced by based on observation and interview, LPA observed the medication cabinet was unlocked and there were medications stored outside of the medication cabinet which poses an immediate health and safety risks to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/26/2025 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250826095648

FACILITY NAME:BURLINGAME SENIOR HOME 2FACILITY NUMBER:
415600648
ADMINISTRATOR:EHSANIPOUR, FERESHTEHFACILITY TYPE:
740
ADDRESS:1738 QUESADA WAYTELEPHONE:
(650) 692-1838
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:6CENSUS: 4DATE:
09/04/2025
UNANNOUNCEDTIME BEGAN:
11:28 AM
MET WITH:Caregiver, Ligaya MunozTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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The facility does not provide quality and quantity meals necessary to meet the needs of the residents
INVESTIGATION FINDINGS:
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On September 4, 2025, Licensing Program Analyst (LPA) Murial Han conducted a 10-day complaint visit. Upon entry, LPA met with the caregiver, and LPA explained the purpose of today's visit. The administrator, Fereshteh Ehsanipour arrived shortly thereafter and assisted with the visit.

Regarding to the allegation of- the facility does not provide quality and quantity meals necessary to meet the needs of the resident, there is no additional details provided by the reporting party.

During today's visit, LPA observed residents were having lunch and they were served mac & cheese, fresh grapes, watermelon, salad, water and juice.

LPA observed the refrigerator and freezer stored with different types of protein, fresh vegetables, drinks, fruits, breads, etc.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 14-AS-20250826095648
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 SENIOR HOME 2
FACILITY NUMBER: 415600648
VISIT DATE: 09/04/2025
NARRATIVE
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LPA interviewed resident #1(R1) who stated that he/she is satisfied with the meals that the facility serves and the meals are nutritious and well balanced.

LPA interviewed staff #1 (S1) who stated that the residents are getting quality and quantity meals. S1 also stated when the food is runny low, she would make a grocery list for the administrator and the administrator would purchase everything within a few hours.

Based on observation and interviews, this allegation is deemed to be unsubstantiated.

Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

This 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: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20250826095648
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 SENIOR HOME 2
FACILITY NUMBER: 415600648
VISIT DATE: 09/04/2025
NARRATIVE
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According to staff #1 (S1) the medication cabinet is too small to fit all the medications.

The administrator acknowledged that the medication is not stored properly because the cabinet is too small to fit all the medications, and it does not lock at all times.

Based on interviews, observation, and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation was determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.
Report was discussed with the Administrator; a copy is provided with Appeal Rights provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5