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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600707
Report Date: 07/12/2023
Date Signed: 07/12/2023 01:43:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/06/2023 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230706114251
FACILITY NAME:MILLBRAE FAMILY CARE HOMEFACILITY NUMBER:
415600707
ADMINISTRATOR:DE LOS REYES ANDAYA, JULITFACILITY TYPE:
740
ADDRESS:487 ANITA DRIVETELEPHONE:
(650) 692-1297
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY:6CENSUS: 5DATE:
07/12/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Wilma De GuzmanTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Staff providing care do not have appropriate training in first aid

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Jeung toured facility and reviewed staff records.

First-aid training was reviewed for 7 staff and 4 have current first aid training; three do not have current first aid training. This deficiency is cited today as part of annual inspection.

Based on records review during annual inspection on this day, this allegation is substantiated. The preponderance of evidence standard has been met. See Facility Evaluation Report for citation.


Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/06/2023 and conducted by Evaluator Audrey Jeung
COMPLAINT CONTROL NUMBER: 14-AS-20230706114251

FACILITY NAME:MILLBRAE FAMILY CARE HOMEFACILITY NUMBER:
415600707
ADMINISTRATOR:DE LOS REYES ANDAYA, JULITFACILITY TYPE:
740
ADDRESS:487 ANITA DRIVETELEPHONE:
(650) 692-1297
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY:6CENSUS: 5DATE:
07/12/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Wilma De GuzmanTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Licensee did not obtain a building permit prior to adding a room
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
In the garage, there is a small room with a bed and desk and exit door that accesses patio. Administrator advised that this room existed as is when facility was initially licensed. A building permit was not requested. As per initial pre-licensing visit on 8/17/07, there was no reference to a room in the garage. However, the original facility sketch reflects a storage room in the garage.

This allegation is determined to be unfounded, meaning that the allegation could not have happened and/or is without a reasonable basis.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2