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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508756
Report Date: 04/23/2024
Date Signed: 04/23/2024 04:05:56 PM


Document Has Been Signed on 04/23/2024 04:05 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:MILLBRAE BOARD & CARE HOMEFACILITY NUMBER:
410508756
ADMINISTRATOR:MADRIAGA, ELENAFACILITY TYPE:
740
ADDRESS:815 MURCHISON DRIVETELEPHONE:
(650) 697-7170
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY:6CENSUS: 5DATE:
04/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Elena MadriagaTIME COMPLETED:
04:00 PM
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LPA Audrey Jeung toured facility and grounds, including 2nd floor staff quarters and attached garage. Clients reside on ground floor, where there are 5 client bedrooms, staff room, 2 full bathrooms, 2 half bathrooms, kitchen, dining/living space and pantry. Upper level for staff consists of 2 bedrooms and bathroom. No accessible bodies of water or fire safety hazards are observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Liquid soap is available at all sinks. Hot water temperature is tested at 115 degrees in main bathroom. Food supply and first-aid kit are inspected. A Disaster and Mass Casualty Plan is posted. There are 5 residents present, and 4 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. Elena Madriaga is a certified RCFE administrator (x 11/24) that oversees facility operations. Client files are reviewed, including medications, which are recorded on Centrally Stored Medications Records.

The following forms are requested to be updated and returned to CCL by 5/7/24:

• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610D Emergency Disaster Plan (9 pages)
• Proof of current liability insurance
- Facility Sketch (including dimensions)

No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed. See Advisory Notes--8 pages--for technical violations to be addressed.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
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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