415600033-1-21-2025-14-AS-MHAN-DD5T7Y-20250121132931

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600033
Report Date: 01/21/2025
Date Signed: 01/21/2025 06:10:23 PM

Document Has Been Signed on 01/21/2025 06:10 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:	MILLS ESTATE VILLA		FACILITY NUMBER:	415600033
ADMINISTRATOR/ DIRECTOR:	MONTANO, DELIA GODOY		FACILITY TYPE:	740
ADDRESS:	1733 CALIFORNIA DRIVE		TELEPHONE:	(650) 692-0600
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY: 47	TOTAL ENROLLED CHILDREN: 0	CENSUS: 33	DATE:	01/21/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Administrator, Delia Montano		TIME VISIT/ INSPECTION COMPLETED:	01:40 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 January 21, 2025 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. Upon entry, LPA met with Resident Care Coordinator, Anne Tiquez and LPA explained the purpose of today's visit. The administrator arrived during the tour of the facility and assisted with the inspection. LPA toured the facility with the resident care coordinator and the 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 observed all bedrooms 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, bathrooms, shower rooms and resident rooms were measured at 105-115 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 at this time. Chemicals, toxins, and sharps objects were locked and inaccessible to residents. 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. During the tour in the kitchen with the resident care coordinator, LPA also observed the kitchen floor underneath the dishwater sinks appeared to be black with grease stains. In addition, LPA observed an opened carton of egg nog with an expiration date of January 11, 2025.

April Cowan	TELEPHONE: (650) 266-8889
Murial Han	TELEPHONE: (619) 209-9761
	DATE: 01/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

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 5

Document Has Been Signed on 01/21/2025 06:10 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MILLS ESTATE VILLA	FACILITY NUMBER: 415600033
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed the kitchen floor underneath the dishwater sinks appeared to be black with grease stains which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/22/2025
	Plan of Correction
1 2 3 4	The administrator will develop a plan in writing to ensure compliance and the plan shall indicate when the floor will be cleaned and send photo(s) of the floor on the completion date. The administrator will submit a copy of the signed and dated plan to CCL by 1/22/2025

Section Cited

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed an opened carton of egg nog with an expiration date of January 11, 2025 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/22/2025
	Plan of Correction
1 2 3 4	The administrator will develop a plan in writing to ensure compliance and the plan shall indicate what is the process that the facility will implement to ensure food items are in good quality. The administrator will submit a copy of the signed and dated plan to CCL by 1/22/2025

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

April Cowan	TELEPHONE: (650) 266-8889
Murial Han	TELEPHONE: (619) 209-9761
	DATE: 01/21/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 01/21/2025 06:10 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MILLS ESTATE VILLA	FACILITY NUMBER: 415600033
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed resident #1 has a bottle of Refresh eardrops at the bedside table which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/22/2025
	Plan of Correction
1 2 3 4	The administrator will develop a plan in writing to ensure all centrally stored medications are locked and inaccessible to residents in care. The plan shall indicate the facility's monitoring process to ensure compliance. The administrator will provide a copy of the signed and dated plan to CCL by 1/22/2025.

Section Cited

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed the medication cart consisted of little plastic containers with medications stored in a few big plastic boxes for the PM shift, HS shift, and AM shift for the following day which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/22/2025
	Plan of Correction
1 2 3 4	The administrator will develop a plan in writing to ensure compliance. The plan shall indicate the facility's monitoring process to ensure compliance. The plan shall include staff training. The administrator will provide a copy of the dated and signed plan to CCL by 1/22/2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

April Cowan	TELEPHONE: (650) 266-8889
Murial Han	TELEPHONE: (619) 209-9761
	DATE: 01/21/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 01/21/2025 06:10 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MILLS ESTATE VILLA	FACILITY NUMBER: 415600033
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 3 out of 5 residents have bedrails without a physician's order which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/22/2025
	Plan of Correction
1 2 3 4	The administrator will develop a plan in writing to ensure compliance and the plan shall indicate the date of the physician's orders will be obtained and provide a copy of the order to CCL when the order is obtained. The administrator will provide a copy of the signed and dated plan to CCL by 1/22/2025.

Section Cited

Oxygen Administration - Gas and Liquid

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed resident #2 (R2) with oxygen in the dining room with other residents and there was no "No Smoking - Oxygen in Use" sign around the area which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/22/2025
	Plan of Correction
1 2 3 4	The administrator will develop a plan in writing to ensure compliance and will provide a photo that the sign is placed in the common areas while oxygen is being used. The administrator will provide a copy of the dated and signed plan and the photo to CCL by 1/22/2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

April Cowan	TELEPHONE: (650) 266-8889
Murial Han	TELEPHONE: (619) 209-9761
	DATE: 01/21/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: MILLS ESTATE VILLA	FACILITY NUMBER: 415600033
	VISIT DATE: 01/21/2025

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

At 9:35AM, during the tour of the facility with the resident care coordinator, LPA observed resident #2 (R2) with oxygen in the dining room with other residents and there was no "No Smoking - Oxygen in Use" sign around the area. According to the resident care coordinator, the "No-smoking - Oxygen in Use" signs are posted by the resident's rooms and not the dining room/dining area.

At 9:56AM, during the tour of the facility with the resident care coordinator, LPA observed resident #1 has a bottle of Refresh eardrops at the bedside table.

At 10:14 AM, during the tour of the facility with the administrator, LPA observed the medication cart consisted of little plastic containers of medications stored in a few big plastic boxes for the PM shift, HS shift, and AM shift for the following day.

A review of (5) resident files was conducted and noted on the LIC 858.
A review of (5) staff files was conducted and noted on the LIC 859.

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 and the resident care coordinator.

A copy of this report and the appeal rights were provided.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

LIC809 (FAS) - (06/04)

Page: 5 of 5