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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601085
Report Date: 06/04/2025
Date Signed: 06/05/2025 02:18:12 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/05/2025 02:18 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:HEARTS AT MILLWOOD ASSISTED LIVINGFACILITY NUMBER:
415601085
ADMINISTRATOR/
DIRECTOR:		ERMITANO, ELI HARTFACILITY TYPE:
740
ADDRESS:416 MILLWOOD DRTELEPHONE:
(650) 777-8166
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
06/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Eli ErmitanoTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 06/04/2025, Licensing program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection. LPA met with Administrator Eli Hart Ermitano and explained the purpose of today’s visit. Currently there are 5 residents and 2 staff present. One of which is the administrator.

This is a single level facility with 8 bedrooms, 6 are for residents, and two are for staff. One staff room is located at the top of the garage. The facility is licensed for age 60 and over. All may be non-ambulatory. With a hospice waiver for 4 residents. At this time there is 2 resident under hospice care. LPA Vado toured the facility both inside and outside. All outdoor and indoor passageway are free and clear of obstructions for emergency exit routes in case of fire or emergency. Facility's ambient temperature is comfortable for residents and LPA. No pools or bodies of water were observed during today's visit on the premises. LPA observed fresh food supplies and emergency one week of nonperishable and two (2) days of perishable foods as in place. Dry goods/can goods are stored in a cabinet located in the garage. Knives are locked in a drawer adjacent to kitchen sink. Toxic chemicals/cleaning supplies are also observed to be locked in the garage of the facility and below the kitchen sink. Both the washer and dryer are observed as functional. There is are an additional freezer in the garage for resident food supplies. There is also a full refrigerator for staff in the garage. Medications are observed to be locked in a hallway closet. Each resident room observed contained the required furniture as outlined in regulations. All resident room also have a half bathroom with exception of bedroom 5, which has a full bathroom with a walk in shower. There is an additional full bathroom located near the front of the facility adjacent to the kitchen with a walk in shower and shower chairs. Non-skid flooring is present in both walk in showers. Resident bathrooms are observed as clean and in good worker order.

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April CowanTELEPHONE: (650) 266-8865
Jaime VadoTELEPHONE: (559) 476-9353
DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: HEARTS AT MILLWOOD ASSISTED LIVING
FACILITY NUMBER: 415601085
VISIT DATE: 06/04/2025
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Facility has functioning smoke detectors within the facility as well as carbon monoxide detectors located in the main hallway. Fire extinguishers are observed with inspection dates of 05/06/2025. Water temperature is tested at 107F in full bathroom adjacent to the kitchen. LPA observed resident linen supplies stored in a hallway closet at the end of the main hallway. LPA inspected the medications and files of 5 residents in care at the facility. Based on review of all resident files, and medications all items are current and logged accurately. 4 staff files are reviewed and they are observed as current. Disaster/fire drill log is reviewed. Disaster drill observed as conducted on 03/27/2025 per training records reviewed. Facility administrator certificate is current expiring 10/20/2026

The following updated forms are requested to be submitted to CCLD by 06/12/2025:

• Copy of updated administrator certificate
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule

There are no citations issued on this day. LIC9102 TV is attached.

Report is reviewed with administrator Eli Hart and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC809 (FAS) - (06/04)
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