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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601112
Report Date: 10/08/2024
Date Signed: 10/08/2024 12:30:40 PM

Document Has Been Signed on 10/08/2024 12:30 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/
DIRECTOR:		PO, GINGERFACILITY TYPE:
740
ADDRESS:1001 HEMLOCK AVETELEPHONE:
(650) 689-5776
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY: 48CENSUS: 48DATE:
10/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator - Maryann LuceroTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 10/08/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection visit. LPA met with administrator Maryann Lucero and explained the purpose of today's visit. There are currently 45 residents in the facility during today's visit and multiple staff.

This is a multi-level facility licensed for residents age range of 60 years and over. Facility is approved for 48 non-ambulatory residents. Hospice waiver is approved for 20 residents. There is only currently 1 residents receiving hospice services. There are no video cameras on site per the administrator. LPA observed the facility kitchen which is clean and observed appliances that are in good repair. Knives are stored and locked in a drawer next to the stove. Perishable and non-perishable food items are observed as in place. Food supplies are stored the kitchen area. Refrigerators and freezers are in operating condition. First aid kit is observed as complete with required items stored in the kitchen of the facility. Medications are observed to be locked in the kitchen in a kitchen cabinet. LPA observed multiple fire extinguishers in place which are all currently within operating range, smoke detector are hard wired through out the facility, carbon monoxide detectors are observed in place through out the facility, and central heating. Facility is equipped with fire sprinklers through out. LPA also observed fire pull stations around the facility. PPE is observed to be in place. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Emergency disaster drills are conducted quarterly and current. This poses an immediate health and safety risk. Water temperature was measured at 112F. Cleaning supplies are observed to be locked in the kitchen and garage.

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SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
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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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: MILLBRAE ASSISTED LIVING HOME
FACILITY NUMBER: 415601112
VISIT DATE: 10/08/2024
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LPA observed all resident rooms as clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident bathrooms are observed as clean and in good worker order. Shower floors are equipped with non-skid mats or flooring. Facility handles some resident monies. These monies are audited and accounted for per review conducted. LPA reviewed 8 resident files and 6 staff files, which are all current.
Facility administrator certificate is observed as current expiring 10/26/25.

The following updated forms are requested to be submitted to CCLD by 10/15/2024:

• Copy of all updated administrator certificates
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or copy of lease

There are no citations issued during today's visit. Report is reviewed with the administrator and a copy is provided during today's visit.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC809 (FAS) - (06/04)
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