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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601112
Report Date: 10/01/2021
Date Signed: 10/01/2021 11:29:05 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:MILLBRAE ASSISTED LIVING HOMEFACILITY NUMBER:
415601112
ADMINISTRATOR:LUCERO, MARY ANNFACILITY TYPE:
740
ADDRESS:1001 HEMLOCK AVETELEPHONE:
(650) 689-5776
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY:48CENSUS: DATE:
10/01/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lucero, Mary Ann, Administrator, Po, Ginger, CEOTIME COMPLETED:
10:30 AM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 48
Census: 48
COMP II Participants: Lucero, Mary Ann, Po, Ginger
Interview Method: Telephone interview
On 10/01/2021, Ginger Po and Mary Ann Lucero in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Katie KeithTELEPHONE: (916) 657-2600
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
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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