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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600707
Report Date: 07/22/2025
Date Signed: 07/22/2025 03:39:02 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/22/2025 03:39 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/
DIRECTOR:		DE LOS REYES ANDAYA, JULITFACILITY TYPE:
740
ADDRESS:487 ANITA DRIVETELEPHONE:
(650) 692-1297
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY: 6CENSUS: 6DATE:
07/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator - Wilma DeguzmanTIME VISIT/
INSPECTION COMPLETED:
02:15 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. The rear fence of the facility has been replaced and repaired based on observations made. 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. 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. According to administrator they are conducting soon due to facility improvements such as solar and fence repair. Water temperature was measured at 109F. 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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NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 07/22/2025
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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. 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 current expiring 05/21/2026 for Wilma De Guzman.

The following updated forms are requested to be submitted to CCLD by 07/29/2025:

• 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

Report is reviewed with Wilma and a copy is provided on this day. Citation issued on following LIC80D and Technical Violation on the following LIC9102TV.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2025 03:39 PM - It Cannot Be Edited


Created By: Jaime Vado On 07/22/2025 at 12:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MILLBRAE FAMILY CARE HOME
FACILITY NUMBER: 415600707

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/01/2025
Section Cited
HSC
1569.695(c)

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§1569.695 Emergency Plans(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is notrequired during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This health and safety code has not been met as evidenced by:
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Facility shall conduct a drill and send evidence of it taking place along with the name of attendees and topic of the drill.
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Based on documentation reviewed, LPA observed that there is no disaster drill log present. Per interviews with staff, a disaster drill has not been conducted in about a year. This poses an immediate health and safety risk to residents and staff in the facility.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2025


LIC809 (FAS) - (06/04)
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