<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508756
Report Date: 03/05/2025
Date Signed: 03/05/2025 01:52:00 PM

Document Has Been Signed on 03/05/2025 01:52 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MILLBRAE BOARD & CARE HOMEFACILITY NUMBER:
410508756
ADMINISTRATOR/
DIRECTOR:		MADRIAGA, ELENAFACILITY TYPE:
740
ADDRESS:815 MURCHISON DRIVETELEPHONE:
(650) 697-7170
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY: 6CENSUS: 4DATE:
03/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator/Licensee - Elena MadriagaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 03/05/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with licensee/Administrator Elena Madriaga. During today's visit there are 4 resident present and 4 staff.

LPA was allowed entry into the facility. This is a two story facility. The facility is licensed for ages 60 and over. 5 may be non-ambulatory. Facility is cleared for 3 hospice residents and one bedridden resident. There is 1 hospice resident as of today's inspection. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked in a lower cabinet in a bright orange tool box. Medications are observed to be locked in a cabinet as well in an area adjacent to the kitchen in between the garage and kitchen. Perishable and non-perishable food items are observed as in place. There is an additional freezer in the garage. Cleaning supplies are observed to be locked. First aid kit is observed as complete with required items. LPA observed that there are multiple fire extinguishers in place last inspected 06/12/2024, smoke detectors, carbon monoxide detectors are observed in place through out the facility, facility smoke detectors are hard wired, and central heating system is functioning. Facility has full sprinkler system through out. Laundry area is also observed as fully operational in the garage. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Exit doors are labeled. Resident bathrooms are observed to be in good working order. Non-skid mats are in place in showers. Water temperature was measured at 118F in a common bathroom in the rear of the facility and at 120F in a resident bathroom. LPA advised on monitoring the water temperature to ensure it does not exceed 120F.

Continued on next page...
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: MILLBRAE BOARD & CARE HOME
FACILITY NUMBER: 410508756
VISIT DATE: 03/05/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 2

LPA observed resident rooms at random and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place. During today's visit LPA reviewed 4 resident files and 4 staff files of which all are current and includes health screenings for all staff. Facility does not handle resident monies. Resident medications are reviewed and are logged appropriately. Facility allows resident's to use licensee's phone for virtual or remote meeting of family members. Emergency keys are available for staff use. Last disaster drill conducted on 12/28/2024. Administrator certificate is current for Elena expiring 11/10/2026.

The following updated forms are requested to be submitted to CCLD by 03/12/2025:

• Copy of updated Administrator Certificates posted in facility.
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or current lease

No citations are issued on this day. Report is reviewed with licensee/administrator Elena Madriaga.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
LIC809 (FAS) - (06/04)
Page: 2 of 2