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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600904
Report Date: 11/18/2021
Date Signed: 11/18/2021 03:34:39 PM

COMPREHENSIVE INSPECTION
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: 35DATE:
11/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mary Ann Lucero and Jason MullenTIME COMPLETED:
03:45 PM
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LPA Audrey Jeung toured facility and grounds, consisting of 25 shared rooms on 2 floors. There are 17 rooms on the second floor and 7 rooms on the ground floor, where there are also 2 offices, medication room, kitchen, living and dining rooms. Rooms are equipped with emergency call systems, which can be activated from bathrooms and bedrooms.
Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. First-aid kit is inspected and complete. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed.
Mary Ann Lucero is a certified RCFE administrator that oversees facility operations.

No deficiencies cited today.

See LIC9102A for observations made today.

See also Facility Evaluation Report dated 11/18/21 for Millbrae Assisted Living Home #41560112.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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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