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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601085
Report Date: 08/11/2022
Date Signed: 08/11/2022 05:00:40 PM

Document Has Been Signed on 08/11/2022 05:00 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:
08/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Eli ErmitanoTIME COMPLETED:
05:15 PM
NARRATIVE
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LPA Jeung met with staff and toured facility. There are 7 bedrooms, 5 of which are occupied as private rooms. There is a room above the garage with 3 beds for overnight caregivers. There are 2 caregivers on-site today. One does not have criminal record clearance.

Based on information previously provided to CCLD, a former staff person worked at facility without criminal record clearance. This information was verified by administrator Ermitano. LPA reviewed staff file.

Based on this information, deficiencies of the CA Code of Regulations, Title 22 are cited on a following page, and civil penalties are assessed:

- Staff #1 has worked at facility for 2 days without criminal record clearance= $100/day x 2 days
- Staff #2 worked at facility from 9/2021 - 6/2022 without criminal record clearance=$100/day x 5 days max.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2022
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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Document Has Been Signed on 08/11/2022 05:00 PM - It Cannot Be Edited


Created By: Audrey Jeung On 08/11/2022 at 04:18 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: 08/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2022
Section Cited
CCR
87355(e)(1)

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CRIMINAL RECORD CLEARANCE
All individuals subject to a criminal record review pursuant to H & S Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility, obtain a CA clearance or a criminal record exemption as required by the Dept.:
This requirement was not met , as staff #1
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Staff #1 and #2 cannot have client contact unless and until criminal record clearances or exemptions are obtained
Proof of correction to be sent to CCLD BY DUE DATE
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is present and caring for clients & Staff #2 worked from 9/21 to 6/22 but do not have criminal record clearances nor exemptions. Licensee failed to ensure that staff who have client contact maintain criminal record clearance or exemption, which poses an immediate health and saftey risk to clients in care. Civil penalty of $200 is assessed for Staff #1 & $500 for staff #2 .
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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:Jackie Jin
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022


LIC809 (FAS) - (06/04)
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