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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601112
Report Date: 02/06/2024
Date Signed: 02/06/2024 01:29:56 PM


Document Has Been Signed on 02/06/2024 01:29 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:MILLBRAE ASSISTED LIVING HOMEFACILITY NUMBER:
415601112
ADMINISTRATOR:PO, GINGERFACILITY TYPE:
740
ADDRESS:1001 HEMLOCK AVETELEPHONE:
(650) 689-5776
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY:48CENSUS: 44DATE:
02/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Resident care coridnator - Alex Manalo and Chief operating officer - Jason MullenTIME COMPLETED:
01:35 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
On 02/06/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - other visit in order to deliver the exclusion letter of a staff person associated to the facility. LPA met with Resident care coordinator - Alex Manalo and Chief operating officer - Jason Mullen and explained the purpose of today's visit.

LPA explained the letter and what it is indicating regarding the staff person and he is no longer able to work in the facility or come in contact with residents in care. According to staff Alex and Jason, the staff person being excluded hasn't contacted the facility, or worked in the facility since September 2023 and has not been on the schedule since then.

Letter is hand delivered to Jason Mullen and report is reviewed with both staff persons.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024
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 1