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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601039
Report Date: 08/03/2023
Date Signed: 08/03/2023 02:19:03 PM


Document Has Been Signed on 08/03/2023 02:19 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
SF COASTAL AC/SC, 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:165CENSUS: 137DATE:
08/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Michael Sharkey and Margaret MadridTIME COMPLETED:
02:30 PM
NARRATIVE
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LPA Jeung met with executive director in response to facility's organizational changes.

RCFE Disclosure Worksheet (LIC606)--including organization chart--was submitted to CCLD, which identifies Cogir Management USA Inc. as licensee/co-licensee. According to Administrative Organization (LIC309), 9388-0045 Quebec Inc. owns 100% interest, and is the parent company of Cogir Management USA Inc. Cadence Senior Living, LLC no longer holds ownership interest in this facility, as it was acquired by Cogir, as per information on Cogir website dated November 2022.

RCFE license was issued to licensee 1201 Operator-LLC/Cadence SL Millbrae LLC,, with Cadence as the management company. Since Cadence was acquired by Cogir, and is now managing the facility, the entity that is now operating the facility is required to apply for RCFE licensure.

Deficiency of the California Code of Regulations, Title 22, is cited on a following page.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
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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Document Has Been Signed on 08/03/2023 02:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: CADENCE MILLBRAE
FACILITY NUMBER: 415601039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
08/10/2023
Section Cited
CCR
87109(d)

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TRANSFERABILITY OF LICENSE
In the case of change of ownership or licensee a new application for license shall be submitted by the prospective new licensee.
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Plan of correction to be submitted to CCLD BY DUE DATE
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This requirement was not met, as Cogir Management USA Inc. acquired Cadence, and application for new licensure has not yet been submitted.
This poses a potential health, safety or personal rights risk to clients in care.
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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.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
LIC809 (FAS) - (06/04)
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