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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601039
Report Date: 02/25/2021
Date Signed: 02/25/2021 02:50:35 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:CADENCE MILLBRAEFACILITY NUMBER:
415601039
ADMINISTRATOR:STROMGREN, KIELFACILITY TYPE:
740
ADDRESS:1201 BROADWAYTELEPHONE:
(650) 742-9150
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY:188CENSUS: DATE:
02/25/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:Kiel Stromgren, AdministratorTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Raygoza made an unannounced case management televisit with Administrator, Kiel Stromgren, in regards to Death Report submitted to CCL Office on 2/24/21.

R1 missed routine dialysis basis appointment for diagnosis of end stage renal disease. Dialysis Care Center telephoned LVN at facility when R1 missed appointment. R1 was found at facility unresponsive and Paramedics were called. Sheriff Deputy called San Mateo's Coroner's Office. R1 was to start on chemo and completely considered independent as R1 was not on any care, or med program.

According to Kiel, Sheriff Deputy who came to investigate believes a possible Death Certificate cause based on health, medications, dialysis, cancer and high blood pressure. Sheriff's guess was a heart attack and due to the health and medications coroner's office most likely will not do an autopsy. Determination on cause of death to be issued on Death Certificate.

Facility is reaching out to family to close everything out and family not aware yet and has been reached out to. Area is locked and no one to go enter room at all. Current number of residents under 60 at facility is 4 residents. The number of residents over 60 is 96%.

END OF REPORT ==============
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha RaygozaTELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2021
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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