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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600154
Report Date: 04/12/2024
Date Signed: 04/12/2024 07:14:11 PM


Document Has Been Signed on 04/12/2024 07:14 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:MAGNOLIA OF MILLBRAEFACILITY NUMBER:
415600154
ADMINISTRATOR:LOLA BORREGOFACILITY TYPE:
740
ADDRESS:201 CHADBOURNE AVENUETELEPHONE:
(650) 697-7700
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY:180CENSUS: 108DATE:
04/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Charito AmorantoTIME COMPLETED:
07:15 PM
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LPA Audrey Jeung toured facility, which consists of 1 and 2 bedroom assisted living and independent living apartments on four floors of this 5- story community. Several apartments are inspected. All apartments have kitchen and washer and dryer. Common rooms--dining room, game room, hair salon, exercise room, pool, whirlpool, library arts and crafts room, library--are located on ground floor, where there are 2 enclosed courtyards. The pool is secured. There are no accessible bodies of water or fire safety hazards observed. Operable carbon monoxide detectors are installed in apartments. Medications and sharps are stored in locked medication room on 2nd floor--inaccessible to clients--a comfortable temperature is maintained, passageways are clear, and lighting is sufficient for comfort and safety. Hot water temperature checked at 107 degrees F in 2nd floor room.
Toilet and bathing facilities are equipped with grab bars and nonskid flooring material and hygiene supplies are maintained. Food supply and first-aid kit are inspected. Emergency signal system is installed in each apartment--in bedroom and bathroom--and transmits visual and audible signal to reception desk as well as 4 administrative offices.
Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Food service staff have current safe food handling certifications, including food and beverage director and executive chef. Quarterly reviews are completed by a registered dietician and reports are maintained; copies of last 2 reports are given to LPA. Lola Borrego and Charito Amoranto are certified RCFE administrators (x 5/24 and (10/24) that oversee facility operations. Some client files and medications records are reviewed.

Staff records, including training, will be reviewed at a later date.

Updated Emergency Disaster Plan (LIC610E) is provided to LPA.

The following information is requested to be submitted to CCL by 4/26/24
- Facility sketch (floor plan)
- Proof of current liability insurance (including coverage limits)
- LIC 309 Administrative Organization

No deficiencies are cited today. Annual inspection to be completed at a later date.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024
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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