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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600154
Report Date: 03/06/2025
Date Signed: 03/06/2025 01:52:22 PM

Document Has Been Signed on 03/06/2025 01:52 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:MAGNOLIA OF MILLBRAEFACILITY NUMBER:
415600154
ADMINISTRATOR/
DIRECTOR:		LOLA BORREGOFACILITY TYPE:
740
ADDRESS:201 CHADBOURNE AVENUETELEPHONE:
(650) 697-7700
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY: 180TOTAL ENROLLED CHILDREN: 0CENSUS: 110DATE:
03/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator - Lola BorregoTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 03/06/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year inspection. LPA met with the administrator Lola Borrego and explained the purpose of today's visit.

The facility is licensed for age range 60 and over. All may be non-ambulatory. License is approved up to 9 hospice residents. 4 are currently on hospice at this time. This is a 5 story facility. The ground floor primarily consists of the dining room, kitchen, game room, hair salon, exercise room, pool, whirlpool, library arts and crafts room, and library. Facility emergency food supply is located also on the ground floor in a large storage room Emergency water is available as well. Facility is equipped with diesel powered emergency backup generator as well also located on the ground floor in an outside area. Floors 1 through 4 are resident living units. Resident population is mixed with assisted living and independent living residents. The facility does not have any dementia residents. Residents rooms on each floor consists of 1 or 2 bedroom apartments. 4 apartments are inspected. All apartments in the facility contains a kitchen, full bathroom, and stacked washer and dryer. Apartments 140, 221, 331, and 409 had water temperature measured. All temperatures recorded between 107F to 120F. All apartments have emergency pull cords in the bedroom and restrooms. Facility does have a pendant call system for those residents that wish to have them. Each apartment also has its own thermostat for residents to use to heat their apartment. There are 2 enclosed courtyards observed and both are in good repair with tables and chairs. The facility swimming pool is secured and residents are required to be buzzed into the swimming area. Cameras are posted in common areas through out the facility. Emergency routes are free and clear of any obstructions. On the fourth floor of all stairwells there are stair chairs in the event of an emergency. Carbon monoxide detectors are installed in all apartments including smoke detectors and fire sprinklers. Fire extinguishers are observed through out the facility with inspection tags dated 10/23/2024. The facility is fully equipped with fire sprinklers through out. Facility conducts emergency drills monthly. Last drill conducted is logged on 02/18/2025.

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April CowanTELEPHONE: (650) 266-8865
Jaime VadoTELEPHONE: (559) 476-9353
DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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 2
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: MAGNOLIA OF MILLBRAE
FACILITY NUMBER: 415600154
VISIT DATE: 03/06/2025
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Kitchen is observed to be fully stocked with 2 day fresh food supply and fully stocked freezer. Emergency food supplies are in place. Ansul and hood system are clean and serviced regularly. All kitchen appliances and washing machines are functioning. Laundry room is observed on the ground floor to be fully operational, clean, and organized. Medications, medical kit, and sharps are stored in locked medication room on 1st floor not accessible to residents. temperature is maintained, passageways are clear, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Hygiene supplies are in place. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. LPA reviewed staff files on this day which appear to be current. Staff training records are observed to be current and in place. Administrator certificate for Lola Borrego is observed as current expiring 05/12/2026.

Inspection will be completed at a later date to review resident records and medications.

The following updated forms are requested to be submitted to CCLD by 03/13/2025:

• Copy of updated Administrator Certificate
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or current lease

Report is reviewed with administrator Lola Borrego and a copy is provided on this day.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC809 (FAS) - (06/04)
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