<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601085
Report Date: 05/22/2023
Date Signed: 05/22/2023 06:39:49 PM

Document Has Been Signed on 05/22/2023 06:39 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:HEARTS AT MILLWOOD ASSISTED LIVINGFACILITY NUMBER:
415601085
ADMINISTRATOR:ERMITANO, ELAINE B.FACILITY TYPE:
740
ADDRESS:416 MILLWOOD DRTELEPHONE:
(650) 777-8166
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY: 6CENSUS: 5DATE:
05/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Eli ErmitanoTIME COMPLETED:
06:45 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. There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. There is no signal system in place, as facility employs awake overnight staff. However, there are 3 clients who have bed alarms, which emit an audible signal when someone gets up from bed. Carbon monoxide detector is tested and operable. First-aid kit is maintained and complete.

This facility is one level, with 7 client bedrooms, 2 full bathrooms, 4 half bathrooms, kitchen, living/dining room, staff room above garage and attached 1-car garage, where the washer and dryer are located. There are 3 beds in staff room above garage and room 4 is being used by female staff; there is a bunk bed and half bathroom in this room. The backyard is fenced and accessible by 5 bedrooms with exit doors.
Medications are stored in locked hall closet. Chemicals and cleaners are stored in garage and locked detached storage shed.
An updated Disaster and Mass Casualty Plan is posted, and copy is given to LPA. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed.
Eli Ermitano is a certified RCFE administrator (x10/24) that oversees facility operations.

Client records and Staff training records will be reviewed at a later date.

The following forms are accessible at www.CDSS.ca.gov and are to be completed and returned to CCL by 6/5/23:

• LIC 308 Designation of Administrative Responsibility, including Board resolution
• LIC 309 Administrative Organization
Proof of liability insurance for $1 million per incident and $3 million in annual aggregate
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: HEARTS AT MILLWOOD ASSISTED LIVING
FACILITY NUMBER: 415601085
VISIT DATE: 05/22/2023
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
26
27
28
29
30
31
32
The following updated forms are provided to LPA during this visit:
• LIC 500 Personnel Report
• LIC 610 Emergency Disaster Plan
• LIC 9282 Infection Control Plan
Proof of current liability insurance

Deficiency of the CA Code of REgulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page.

Annual inspection to be continued and completed on a later date, due to time constraints.
.

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/22/2023 06:39 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/22/2023 at 06:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HEARTS AT MILLWOOD ASSISTED LIVING
FACILITY NUMBER: 415601085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(4)

MAINTENANCE AND OPERATION
Grab bars shall be maintained for each toilet; bathtub and shower used by residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, as full bathroom in room 5 does not have grab bar in shower stall, which poses a potential health, safety or personal rights risk to persons in care.
This room was formerly used by staff, and bathroom was not used by residents.
POC Due Date: 06/05/2023
Plan of Correction
1
2
3
4
Grab bars will be installed in bathroom in room 5. Proof of correction to be submitted to CCLD BY DUE DATE.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Cara Smith
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3