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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601039
Report Date: 05/28/2021
Date Signed: 05/28/2021 03:50:33 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: 102DATE:
05/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Kiel StromgrenTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Jeung met with Administrator, Kiel Stromgren, to follow up on Death Report submitted to CCL Office on 2/24/21.

The Dept. has investigated the circumstances of the death of client on 2/23/21 and determined that his death was not questionable, but natural. Client was found in his room unresponsive and 9-1-1 was called. Facility records document that client was independent and did not require--nor did he receive--any care or supervision, including medication management.

Based on Death Certificate, cause of death was determined to be related to heart failure.

No deficiencies are cited based on this incident.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
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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