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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600904
Report Date: 07/08/2021
Date Signed: 07/08/2021 03:09:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MILLBRAE ASSISTED LIVING CENTER LLCFACILITY NUMBER:
415600904
ADMINISTRATOR:LUCERO, MARY ANNFACILITY TYPE:
740
ADDRESS:1001 HEMLOCK AVETELEPHONE:
(650) 689-5776
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY:48CENSUS: 39DATE:
07/08/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Mary Ann Lucero and Frances ParkTIME COMPLETED:
03:30 PM
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LPA Jeung met with administrator and director of administration to discuss recent changes in administrative organization. According to Ms. Park, the facility is operated by a partnership consisting of Millbrae Assisted Living Center LLC and Millbrae Assisted Living Home LLC, the latter of which has been contracted to manage facility operations.

The following documents are requested to be submitted to CCLD by 7/16/21:

- Updated Administrative Organizations (LIC309)
- Entire lease agreement between Millbrae Nursing Home, Inc. and Millbrae Assisted Living Home LLC
- Covid Mitigation Plan (LIC808)

Upon entry, LPA signed visitor log, but was not assessed for Covid risk, not asked about Covid exposure, nor required to provide contact number. LPA advised Ms. Lucero that Visitor Log must include the following:
- Visitor name
- DAte and time
- Body temperature
- Responses to risk assessment questions, including Covid symptoms and possible exposure
- Contact information

Ms. Lucero to implement revised Visitor Log within 24 hours and submit a sample page to LPA by 7/9/21
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
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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