Burlingame Villa, INC.

FACILITY EVALUATION REPORT

COMPLAINT INVESTIGATION REPORT

The facility underwent a Case Management visit to follow up on a reported incident concerning a resident's back pain and compression fracture. The Licensing Program Analyst observed the resident and interviewed the administrator. No deficiencies were cited during this visit.

The facility underwent a Case Management visit to follow up on a reported incident concerning a resident's back pain and compression fracture. The Licensing Program Analyst observed the resident and interviewed the administrator. No deficiencies were cited during this visit.

The unannounced case management visit was conducted to follow up on a reported medication incident. The primary deficiency cited relates to medication administration errors, specifically failing to ensure the right resident received the right medication. Both citations are classified as Type A due to the immediate health and safety risk posed by the medication error.

This report details the findings of a complaint investigation conducted on June 18, 2025. The allegations regarding inappropriate caregiver conduct and interference with activities were investigated by interviewing the administrator, staff, and the responsible party who hired the private caregiver. All allegations were ultimately deemed unsubstantiated due to a lack of preponderance of evidence.

The facility underwent an unannounced annual inspection on May 5, 2025. The inspector noted that the facility was clean, well-maintained, and that residents were participating in activities. No deficiencies were cited during this inspection.

The facility underwent a Case Management visit to follow up on two reported incidents involving medication errors. The investigator interviewed staff and reviewed records, noting that the facility has taken corrective actions for both incidents. No deficiencies were cited during this inspection.