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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600033
Report Date: 04/14/2021
Date Signed: 04/15/2021 09:18:13 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: 33DATE:
04/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Maria Jereline MadelosoTIME COMPLETED:
03:00 PM
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On April 14, 2021, at around 1:45pm, Licensing Program Analyst (LPA) Michael Garcia conducted an unannounced case management tele-inspection in response to an incident that the facility had self-reported between Resident 1 (R1) and Staff 1 (S1). Due to COVID-19 pandemic, the inspection was conducted remotely, via video call, with Maria Jereline Madeloso, manager.

Today, LPA conducted records review and interviewed Maria and Staff 2 (S2) about the incident.

Maria shall ensure to email the following documents to LPA within 24 hours of this report:
- April 10, 2021 Unusual Incident Report regarding S1 and R1.
- April 2021 staff schedule.
- R1’s most current Physician’s Report.
- Current resident roster.
- S1 training records regarding rights of residents for the past year.
- Caregiver notes regarding the incident.

Report was reviewed and discussed with Maria at the end of the tele-inspection. An electronic copy of the report was emailed to Maria for signature.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Michael GarciaTELEPHONE: (650) 380-4608
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
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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