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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601039
Report Date: 01/06/2022
Date Signed: 01/06/2022 06:29:01 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: 118DATE:
01/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Kiel Stromgren and Lorena PenneTIME COMPLETED:
05:44 PM
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In response to capacity change application for 165 elderly residents--105 non-ambulatory and 60 ambulatory--LPA Jeung toured new memory care unit, consisting of 6 shared rooms on ground floor and 6 shared rooms on 1st floor (2nd level). Each unit has a shared bathroom with shower stall; grab bars are installed in shower stalls and by toilets. There are Arial call alerts installed in each unit, and in each of the bathrooms, but Mr. Stromgren stated that these will not be used by the residents in this unit due to cognitive limitations. All units have either a sliding glass door that accesses a metal railing or sliding windows; all are secured and only open 4 inches. There is a dining room with warming pads on both floors; LPA observed dining chairs for 12 in each dining room. Fire clearance has been approved, including two 30-second delayed egresses on both floors of memory care unit. An enclosed courtyard on the ground floor is secured by a gate that is accessed by a keypad, leading to the parking lot. Stairwells are also accessed by a keypad.

LPA also toured existing memory care unit on 1st floor (2nd level), where 14 residents reside. Paper towels are not available in bathrooms, nor were liquid pump hand soap and handwashing reminder signs.

The following observations are made and discussed with Mr. Stromgren:
1. There is no COVID signage in the memory care unit, including handwashing, mask wearing and social distancing reminder signs.
2. Liquid soap and paper towels are not present in bathrooms.
3. Vestibule on ground floor accesses memory care unit and parking lot. The vestibule can be accessed from the memory care unit by a 30-second delayed egress. This room designation is currently unknown. During the pandemic, LPA advises that the vestibule not be used as an egress.

Memory care unit is not yet ready to accommodate residents. LPA to be notified when the above items have been addressed.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
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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