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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601039
Report Date: 09/27/2024
Date Signed: 09/27/2024 02:14:31 PM


Document Has Been Signed on 09/27/2024 02:14 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: 112DATE:
09/27/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Bueisnes Office Manager - Tina PedagatTIME COMPLETED:
02:30 PM
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On 09/27/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - other visit. LPA met with Tina Pedagat Business Office Manager and explained the purpose of today's visit.

During today's visit LPA Vado is requesting documentation related to complaint # 14-AS-20230804102303 regarding a resident in care at the time of the complaint investigation in 2023. LPA requested the date specific document but the facility does not have the requested record to provide to the Department regarding R1's ADL reference sheet from 06/27/2023. This poses a potential health and safety risk to residents in care. Due to the facility not having this document not being able to be found a citation is issued on this day.

Citation issued on the attached LIC809D.

Report is reviewed with Tina Pedagat and a copy is provided during on this day.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
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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Document Has Been Signed on 09/27/2024 02:14 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: CADENCE MILLBRAE
FACILITY NUMBER: 415601039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2024
Section Cited
CCR
87506(e)

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87506(e) Resident Records - Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This regulation has not been met as evidenced by:
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The facility shall develop a plan of correction addressing how this regulation will be met at all times. Plan of correction to be received by 10/04/2024.
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Based on recrod request, the facility is unable to provide a resident document dated 06/27/2023 that should be maintained for 3 years following the termination of service to the resident.
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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: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
LIC809 (FAS) - (06/04)
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