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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 06:45:00 PM


Document Has Been Signed on 05/27/2022 06:45 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 - IncidentUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Kiel StromgrenTIME COMPLETED:
06:30 PM
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LPA Jeung observed memory care client who resides in room 2103A, and observed location of the room on the 2nd floor--identified as the 1st floor. As per Incident Report submitted to CCLD, client left building unattended on 3/13/22, and was found an hour later, at his residence, less than a mile away. Given that he resides on the 2nd floor--and the elevator can only be accessed by entering a code and there is a 30-second delayed egress on the ground floor--staff are unable to determine how resident was able to get to the ground floor and exit the building. Physician's Report and updated Service Plans were submitted to LPA upon request and reviewed. In addition, documentation of staff participation in an Elopement Drill was submitted.

No deficiency cited.
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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