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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600707
Report Date: 08/27/2024
Date Signed: 08/27/2024 02:47:41 PM


Document Has Been Signed on 08/27/2024 02:47 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: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: 6DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator - Wilma DeguzmanTIME COMPLETED:
03:30 PM
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On 08/27/2024, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with administrator Wilma Deguzman. There are currently 5 residents in the facility and one resident is out of the facility with family.

This is a single level facility licensed for residents age range of 60 years and over all of which may be non-ambulatory. License is approved for 3 hospice residents. There is 1 hospice resident as of today's inspection visit. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. There are no video cameras on site per the administrator. LPA observed the facility kitchen which is clean and observed appliances that are in good repair. Knives are stored and locked in in kitchen drawer adjacent to the stove. Perishable and non-perishable food items are observed as in place. There is an additional refrigerator and freezer in the garage area which carries additional food supplies for resident use. First aid kit is observed as complete with required items. Medications are observed to be locked in the kitchen in a lockable cabinet. LPA observed that there are two fire extinguishers in place which are currently within operating range, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating. Facility is not equipped with fire sprinklers. PPE is observed to be in place stored in a closet within a resident bathroom. Laundry area is also observed as fully operational in the garage. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 08/27/2024. Water temperature was measured at 107F. Cleaning supplies are observed to be locked in beneath the kitchen sink and additional toxins and cleaning supplies are observed to be locked in the garage.

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SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024
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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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: MILLBRAE FAMILY CARE HOME
FACILITY NUMBER: 415600707
VISIT DATE: 08/27/2024
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LPA observed all resident rooms and all are observed as clean, free of odors, and contained all the required furniture per regulatory recommendations. Extra resident linen supplies are observed as in place in hallway closets. There are two resident full bathrooms, and a half bath in room 3, all are observed which are in good repair. Shower floors are equipped with non-skid mats. Facility does not handle resident monies. Medications and logs are observed today as current. During today's inspection LPA reviewed 4 resident files which are current and 3 staff files which are current. Administrator certificate is observed as expired on 05/2024 but currently shows as pending online and payment has been received.

The following updated forms are requested to be submitted to CCLD by 09/03/2024:

• Copy of updated administrator certificates as there are more than one administrator
• 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 copy of lease

No citations issued on this day. Report is reviewed with Wilma 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: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC809 (FAS) - (06/04)
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