415601039-7-26-2021-14-AS-AJEG-C5ATTL-20210726150054

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415601039
Report Date: 07/26/2021
Date Signed: 07/26/2021 03:02:49 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 MILLBRAE		FACILITY NUMBER:	415601039
ADMINISTRATOR:	STROMGREN, KIEL		FACILITY TYPE:	740
ADDRESS:	1201 BROADWAY		TELEPHONE:	(650) 742-9150
CITY:	MILLBRAE	STATE: CA	ZIP CODE:	94030
CAPACITY:	188	CENSUS: 105	DATE:	07/26/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Kiel Stromgren		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	LPA Audrey Jeung toured facility and grounds, consisting of 158 studio and 1-bedroom units on 5 floors. Eighteen rooms comprise the memory care unit on the first--not ground level--floor, where there are 2 exits equipped with a 30 second delayed egress: one is tested and opened immediately with an alarm. This unit has a small dining room. The rest of the building accommodates independent and assisted living residents, including non-ambulatory, bedridden and hospice residents. Rooms are equipped with emergency call systems, which can be activated from bathrooms and bedrooms. There is a large dining room for independent and assisted living residents on the 1st--not ground level--floor, with an adjacent enclosed outdoor courtyard. Near the main dining room is the activity room and piano lounge. No accessible bodies of water or fire safety hazards observed. Facility is currently undergoing some construction and renovation: Ground floor and 1st floor rooms in building 2 are being renovated to accommodate a new memory care unit; beauty salon on ground floor is being converted to resident room and staff office; new beauty salon is located on ground level behind reception desk; med room on 1st floor is being enlarged; two additional resident rooms are being added; upon completion of new memory care unit, current memory care unit will be renovated and upgraded to accommodate assisted living or independent residents. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Liquid soap is available in common bathrooms and private bathrooms of independent and assisted living bathrooms, but not in memory care bathrooms, for the safety of memory care residents. First-aid kit is inspected and complete. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Kiel Stromgren is a certified RCFE administrator (x 5/22) that oversees facility operations.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021

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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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
	VISIT DATE: 07/26/2021

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The following updated forms/information are requested to be submitted to CCLD BY 8/2/21:
• LIC 500 Personnel Report
• Proof of current Liability Insurance
• LIC 808 COVID Mitigation Plan
Emergency Disaster Plan (LIC 610E revised) is given to LPA today.
No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are cited.
See Technical Violations and Advisories issued.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021

LIC809 (FAS) - (06/04)

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