Community Care Licensing

Document Has Been Signed on 11/21/2023 12:53 PM - It Cannot Be Edited

FACILITY NAME:	MILLBRAE FAMILY CARE HOME		FACILITY NUMBER:	415600707
ADMINISTRATOR:	DE LOS REYES ANDAYA, JULIT		FACILITY TYPE:	740
ADDRESS:	487 ANITA DRIVE		TELEPHONE:	(650) 692-1297
CITY:	MILLBRAE	STATE: CA	ZIP CODE:	94030
CAPACITY: 6		CENSUS: 6	DATE:	11/21/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Wilma De Guzman		TIME COMPLETED:	01:00 PM

SUPERVISORS NAME: Cara Smith LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023

Link to Parent Document Below:

FACILITY NAME: MILLBRAE FAMILY CARE HOME	FACILITY NUMBER: 415600707
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/21/2023

Type A

Section Cited

CCR

87606(c)

(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above, as one out of 6 residents is bedridden, per MD report, which poses an immediate health, safety or personal rights risk to persons in care. Client #6 is bedridden, per MD report dated 8/2022. Facility maintains fire clearance for 6 Non-ambulatory residents.
	POC Due Date: 11/22/2023
	Plan of Correction
1 2 3 4	Plan of correction to be submitted to CCLD BY DUE DATE

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Cara Smith LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023

Link to Parent Document Below:

FACILITY NAME: MILLBRAE FAMILY CARE HOME	FACILITY NUMBER: 415600707
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/21/2023

Type B

Section Cited

HSC

1569.696(a)

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff record review, the licensee did not comply with the section cited above, as 3 out of 3 staff have not received required 4 hours of training on postural supports, restricted health conditions, and hospice care, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/12/2023
	Plan of Correction
1 2 3 4	Proof that 3 staff have received 4 hours of training on postural supports, restricted health conditions, and hospice care till be sent to CCLD BY DUE DATE.

Type B

Section Cited

CCR

87705(c)(5)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on client records review, the licensee did not comply with the section cited above, as 4 out of 4 clients diagnosed with dementia have MD reports that are more than 1 year old and 3 out of 4 clients diagnosed with dementia have appraisals that are more than 1 year old, which poses a potential health, safety or personal rights risk to persons in care. Clients #1, #2, #3, #5 are diagnosed with dementia, but MD reports are over one year old and appraisals for clients #1, #3, #5 are over one year old.
	POC Due Date: 12/12/2023
	Plan of Correction
1 2 3 4	Updated MD reports and appraisals will be submitted to CCLD BY DUE DATE for above referenced residents who are diagnosed with dementia

SUPERVISOR'S NAME: Cara Smith LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023

Link to Parent Document Below:

FACILITY NAME: MILLBRAE FAMILY CARE HOME	FACILITY NUMBER: 415600707
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/21/2023

Type B

Section Cited

CCR

87465(h)(6)

INCIDENTAL MEDICAL CARE A record of centrally stored prescription medications for each resident shall be maintained and include names of the resident for whom prescribed, prescribing physician and pharmacist, drug name, strength and quantity, dates filled, started & expiration, prescription number and instructions: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of client records and centrally stored medications, the licensee did not comply with the section cited above. All medications for at least 2 residents are not logged on CSMR (LIC622), which poses a potential health, safety or personal rights risk to persons in care. Six RX medications filled in November 2023 and 1 med filled in October 2023 for client #4 are not logged and meds for client #3 and client #5 are not logged since 8/23 and 9/23, respectively.
	POC Due Date: 12/12/2023
	Plan of Correction
1 2 3 4	Plan/proof of corrections to be submitted to CCLD BY DUE DATE, to acknowledge and ensure that medications are logged in CSMR promptly upon receipt.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Cara Smith LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023