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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600033
Report Date: 12/10/2020
Date Signed: 12/10/2020 11:40:49 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MILLS ESTATE VILLAFACILITY NUMBER:
415600033
ADMINISTRATOR:MONTANO, DELIA GODOYFACILITY TYPE:
740
ADDRESS:1733 CALIFORNIA DRIVETELEPHONE:
(650) 692-0600
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:47CENSUS: 36DATE:
12/10/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Delia MontanoTIME COMPLETED:
11:10 AM
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On this date, Licensing Program Analyst (LPA) Michael Garcia conducted a Case Management visit to provide Technical Assistance to the facility regarding COVID-19. Due to the pandemic, the visit was conducted remotely via video call. The visit was conducted with Delia Montano, executive director/administrator, along with Angela Brand, RN of the California Department of Public Health.

The facility's COVID-19 protocol was discussed. The facility's COVID-19 screening was reviewed. Areas where staff and residents may congregate were toured.

The visit resulted with the following recommendations:
- Incorporate symptoms of COVID-19 listed on the PLEASE READ BEFORE ENTERING poster to the facility's COVID-19 screening criteria.
- Ensure all trash bins have lids.
- Prepare DROPLET PRECAUTIONS signs to post outside the door of COVID-19 positive residents.

Administrator is to email a dated and signed plan regarding the above suggestions to LPA within 24 hours.

Report was reviewed and discussed with Administrator at the end of the inspection.

An electronic copy of the report was emailed to Administrator for signature.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Michael GarciaTELEPHONE: (650) 380-4608
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2020
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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