<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601039
Report Date: 11/08/2024
Date Signed: 11/08/2024 01:28:10 PM

Document Has Been Signed on 11/08/2024 01:28 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CADENCE MILLBRAEFACILITY NUMBER:
415601039
ADMINISTRATOR/
DIRECTOR:		JOAN NEWMANFACILITY TYPE:
740
ADDRESS:1201 BROADWAYTELEPHONE:
(650) 742-9150
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY: 165CENSUS: 121DATE:
11/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Administrator - Joan NewmanTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/08/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - incident visit in response to an SOC 341 report received on 11/07/2024. LPA met with administrator Joan Newman and explained the purpose of today's visit.

During today's visit LPA conducted interviews and collected pertinent documents regarding the resident. LPA also discussed the incident with the local long term care ombudsman assigned to this facility regarding the incident. Facility staff investigated the reported incident but could not come to any conclusions. The person in question as described by the resident, could not be a staff member as there are no staff matching the description of the supposed person. Male residents in the area also do not match the description provided. Facility does not have cameras in common areas of the facility. Per the facility the incident was reported to the hospice agency who then reported to the facility. As a precaution the facility has implemented a plan to assist the resident in order to prevent any issues in regards to males entering the resident's room. The facility has assigned no male staff to the resident, but if there is a male med-tech needs to visit the resident, they are to be accompanied a female care partner. The facility met with the family and they are aware and are working with the facility at this time. No further issues were discussed.

No citations issued.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1