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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601039
Report Date: 05/27/2022
Date Signed: 05/27/2022 06:54:35 PM


Document Has Been Signed on 05/27/2022 06:54 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
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:165CENSUS: 127DATE:
05/27/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Kiel StromgrenTIME COMPLETED:
07:00 PM
NARRATIVE
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In response to information that staff and /or clients had COVID infection, LPA Jeung met with Kiel Stromgren, who confirmed that there were 11 staff and 7 clients with COVID since 5/14/22. Written notices from the administrator were available to clients at the front desk starting over a week ago, stating that due to persons infected with COVID, "everyone" should wear a mask. Administrator failed to report COVID cases to CCLD and San Mateo County Public Health Department.

LPA toured facility with administrator and observed that rooms where COVID clients reside are not identified as restricted entry, with isolation carts outside of rooms. PPE supplies are inspected, and facility lacks 30-day supplies of gloves, masks, and N95 respirators. See Technical Advisory Note. Of 7 caregivers currently on duty, there is no record of daily temperature and COVID symptom checks for 4 of them. Daily logs for temperature and COVID symptom checks for clients is not maintained.

Public restrooms are observed with handwashing reminder signs and liquid soap and paper towels available.

Deficiencies of the California Code of Regulations, Title 22, are cited on a following page.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
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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Document Has Been Signed on 05/27/2022 06:54 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: CADENCE MILLBRAE
FACILITY NUMBER: 415601039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2022
Section Cited

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REPORTING REQUIREMENTS
Licensee shall furnish to CCLD reports, including written report within 7 days of the occurrence of an epidemic outbreak, which threatens the welfare, safety or health of residents, personnel or visitors. Report shall be made within 24 hours either by telephone or fax to CCLD & to the local health officer when appropriate.
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Report shall include the resident's name, age, sex, date of admission... This requirement was not met, as at least 14 staff & 7 clients with Covid were not reported to CCLD. Licensee failed to report COVID infections to CCLD and County Public Health Dept., which poses an immediate health and safety risk to clients in care.
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Type A
05/31/2022
Section Cited

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INFECTION CONTROL REQUIREMENTS
All staff &volunteers providing direct care to a resident who has a communicable disease shall wear appropriate PPE to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings
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and eye protection. This requirement was not met, as staff M.L. was observed through open door to be assisting COVID client wearing surgical mask--no gloves, no isolation gown, no N95. Licensee failed to ensure that staff with direct contact to clients with COVID are appropriately attired in full PPE, which poses an immediate health, safety, or personal rights risk to clients in care.
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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: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/27/2022 06:54 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: CADENCE MILLBRAE
FACILITY NUMBER: 415601039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2022
Section Cited

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PERSONAL RIGHTS IN ALL FACILITIES Residents in all RCFEs shall have the personal rights to be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met, as procedures for mitigation of COVID are not being followed: rooms of clients with COVID infection are not designated as restricted entry, nor are
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there isolation carts outside of rooms for care staff to don and doff full PPE when entering and exiting rooms. Staff and residents are not being screened daily for COVID symptoms and fever. Licensee failed to ensure that procedures to mitigate the spread of COVID infections are being followed according to facility's COVID plan, which poses an immediate health, safety or personal rights risk.
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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: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
LIC809 (FAS) - (06/04)
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