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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600033
Report Date: 02/14/2024
Date Signed: 02/14/2024 06:07:44 PM


Document Has Been Signed on 02/14/2024 06:07 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: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: 32DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator, Delia MontanoTIME COMPLETED:
01:05 PM
NARRATIVE
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On February 14, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with administrator and explained the purpose of today's visit.

LPA toured the facility with administrator. The facility is a two story building. No accessible bodies of water or fire safety hazards observed. The indoor and outdoor passageways were free of obstruction.

LPA randomly toured 10 resident rooms at the facility. All bedrooms observed with emergency call buttons, adequate furniture, and sufficient lighting. Bathrooms/shower rooms and toilets have grab bars and non-skid mats. Hot water temperature in the kitchen, 2nd floor living/activity room, shower/bathrooms and resident rooms were measured at 105-113 degrees F. LPA toured the kitchen and observed 2-days perishable and 7- days non-perishable present.

Linen closet was reviewed. Bed sheets, linens, and towels were observed to be sufficient.

Medications are locked in the medication room on the 1st floor and inaccessible to residents in care.

Chemicals, toxins, and sharps objects were locked and inaccessible to residents.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: MILLS ESTATE VILLA
FACILITY NUMBER: 415600033
VISIT DATE: 02/14/2024
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Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher was last serviced on 2/2/2024. Fire drill records observed to be sufficient.

LPA reviewed 5 resident records that contained Admission Agreement, Appraisal Needs and Service Plan, Resident Identification information, Pre-appraisal assessment, and 1 out of 5 resident's medical assessment (LIC 602) was not updated.

LPA reviewed 4 staff files and all of them contained personnel records, health screening, Abuse Statement, First Aide/CPR, Criminal Record Statement, fingerprint cleared, and training records.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with administrator.

A copy of this report and the appeal rights were provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/14/2024 06:07 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: MILLS ESTATE VILLA
FACILITY NUMBER: 415600033

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87705(c)(5)


This requirement is not met as evidenced by: Care of Persons with Dementia
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 1 out of 5 residents who has a diagnosis of Dementia did not have an updated Medical Assessment (LIC 602) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2024
Plan of Correction
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The administrator and/or designee will review the LIC 602 for all the residents to ensure compliance. After the review, the administrator/licensee will provide a dated and signed statement stating that this process has been completed, and a plan to ensure compliance. The administrator will provide a copy of the updated LIC 602, a copy of the signed and dated statement and a copy of the plan to CCL by 2/21/2024.
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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
LIC809 (FAS) - (06/04)
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