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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601085
Report Date: 05/22/2023
Date Signed: 05/22/2023 06:35:02 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/04/2022 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220804135812
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
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Imelda Mendoza and Eli ErmitanoTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Facility operates over capacity.
INVESTIGATION FINDINGS:
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Based on information reported by and obtained from facility staff, this allegation is substantiated. The preponderance of evidence standard has been met.

Upon review of current and former residents, there were 7 clients residing in facility from 1/28/22 through 3/22/22. Facility is licensed for 6.

Deficiency of the California Code of Regulations, Title 22 is cited on a following page.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 14-AS-20220804135812
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2023
Section Cited
CCR
87204(a)
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LIMITATIONS--CAPACITY & AMBULATORY STATUS
A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time.
This requirement was not met, as there were
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Administrator submitted plan of correction to CCLD, acknowledging oversight and assurance that this will not happen again.

Deficiency corrected and cleared.
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7 clients residing in facility for 53 days in 2022. Licensee failed to abide by limitations of RCFE licensure, which posed 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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
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
LIC9099 (FAS) - (06/04)
Page: 2 of 2