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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601039
Report Date: 08/20/2024
Date Signed: 08/20/2024 01:16:48 PM


Document Has Been Signed on 08/20/2024 01:16 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:JOAN NEWMANFACILITY TYPE:
740
ADDRESS:1201 BROADWAYTELEPHONE:
(650) 742-9150
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY:165CENSUS: 108DATE:
08/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator - Joan NewmanTIME COMPLETED:
01:30 PM
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On 08/20/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with the executive director Joan Newman and explained the purpose of today's visit. There are currently 91 residents in assisted living and 17 in memory care.

LPA was allowed entry into the facility. This is a multi-level facility approved for all residents allowed to be non-ambulatory, five bedridden, and a hospice clearance for 14 residents. This facility does have a secured memory care area. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked and secured in the kitchen. Perishable and non-perishable food supplies are observed as in place. Kitchen grade fire extinguisher is observed as in place and with an inspection date of 06/08/2024. First aid kit is observed as complete with required items as observed in medication room. Medications are observed to be locked in cabinets and medication cart in the medication room. LPA reviewed resident medications at random and observed them as current. LPA observed that there are multiple fire extinguishers in place on each floor with an inspection date of 06/12/2024, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating and air conditioning. Laundry areas are also observed as fully operational. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 08/07/2024. Water temperature was measured at 111F in resident rooms at random. Cleaning supplies are observed to be inaccessible to residents in care. Resident rooms are observed at random. LPA observed five resident rooms and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations.

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SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: CADENCE MILLBRAE
FACILITY NUMBER: 415601039
VISIT DATE: 08/20/2024
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Resident linen supplies are observed as in place. P&I monies are not handled by the facility. LPA reviewed four staff files and five resident files during today's inspection and all files are observed as current. Staff conducting via Relias and observed as current. Administrator certificate is current expiring 02/28/2025.

The following updated forms are requested to be submitted to CCLD by 08/27/2024:

• Copy of updated Administrator Certificate
• Copy of facility's liability insurance
• LIC400 Affidavit Regarding Client/Resident Cash Resources
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or copy of lease

No citations issued. Report is reviewed with Joan and a copy is provided on this day.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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