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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202375
Report Date: 06/13/2022
Date Signed: 06/13/2022 02:12:54 PM


Document Has Been Signed on 06/13/2022 02:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:MILLBRAE CARE HOMEFACILITY NUMBER:
107202375
ADMINISTRATOR:ABALOS, CORA MFACILITY TYPE:
740
ADDRESS:1626 W MILLBRAETELEPHONE:
(559) 765-8335
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 4DATE:
06/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Leticia Rodriguez-Assistant AdministratorTIME COMPLETED:
02:15 PM
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On 6/13/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with Teresita Flores, Caregiver. Leticia Rodriguez-Assistant Administrator was called and arrived shortly and conduct tour with LPA. All four residents were present during the inspection.

Upon entry facility staff was observed with no facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. Social distancing and cough etiquette postings not observed.

Cleaning supplies were stored and locked under kitchen sink. LPA checked residents’ locked medications. Food supply was checked and appeared to be an adequate supply. 30 days PPE not observed.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed 4 single occupant room. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. Hand washing posting observed by bathroom sinks.

The exterior tour was conducted. At 1:28 p.m., LPA and Assistant Administrator observed side exit fence non-functioning. Side gate exit not able to open without falling. Staff records were reviewed for good health and infection control training. All residents record reviewed to have updated emergency contact information.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 6/20/22. The following updated forms were requested: Lic 308, Lic 309, Lic 500, Lic 610E, Lic 9020, control of property, and current liability insurance. LPA received copy of Administrator certificate. A copy of this report and appeal rights was provided to Assistant Administrator.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/13/2022 02:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MILLBRAE CARE HOME
FACILITY NUMBER: 107202375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 1:28 p.m., LPA and Assistant Administrator observed side exit fence nonfunctioning. Side gate exit not able to open without falling. Side gate exit was observed not self-closing and self-latching. This poses a potential health, safety, and personal rights risk to residents in care.
POC Due Date: 06/26/2022
Plan of Correction
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Assistant Administrator will be provided proof of side gate exit repaired or replaced to be self-latching and self-closing. Proof will be submitted to CCL by due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
LIC809 (FAS) - (06/04)
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