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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600904
Report Date: 09/08/2021
Date Signed: 09/08/2021 06:10:21 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: 38DATE:
09/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Mary Ann UceroTIME COMPLETED:
06:15 PM
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In response to Incident Reports submitted to CCLD regarding client #1, LPA Jeung met with administrator and reviewed client's file. Despite case management meetings with case workers involved in this client's care coordination and placement, he continues to defy facility's house rules for curfew, ingesting alcohol and cannabis, maintaining good hygiene, and bringing unauthorized food and items into facility. Thirty-day notice of eviction is issued today, and copy is given to LPA. Medical evaluation is scheduled, and administrator to attempt to re-schedule appointment to earlier date.

Administrator is reminded to continue to diligently document this ongoing situation--including updating the Appraisal and Physician's Report to reflect client's change in condition. LPA to be informed of any significant changes.

No deficiencies of the CA Code of REgulations are cited today.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
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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