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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601112
Report Date: 11/03/2025
Date Signed: 11/03/2025 05:05:47 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/03/2025 and conducted by Evaluator Komal Curley
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20251003123635
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: 45DATE:
11/03/2025
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Administrator, Mary Ann LuceroTIME COMPLETED:
12:19 PM
ALLEGATION(S):
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Improper disposal of contaminated waste paper
Client's hygiene needs are not met by staff
Staff violated client's personal rights
INVESTIGATION FINDINGS:
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On November 3, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Mary Ann Lucero and explained the purpose of the visit.

Regarding the allegation, improper disposal of contaminated waste paper, according to the reporting party, clients are instructed to throw away used toilet paper in trash cans located next to shower and sink. In addition, the reporting party indicated staff empty trash cans once a day at 10am.

During the investigation, LPA interviewed staff and observed a random sample of client bathrooms. According staff interviewed, it was indicated that clients were instructed to throw contaminated toilet paper in the toilet and to throw contaminated paper towels in the trash can to avoid the toilet from being clogged and to avoid any sort of diseases/odors. In addition, staff interviewed indicated, trash is taken out 3x a day at the end of each shift. Based on observations, LPA observed waste paper to be properly disposed of. (continue to 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 14-AS-20251003123635
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/03/2025
NARRATIVE
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Regarding the allegation, client's hygiene needs are not met by staff, according to the reporting party, Client 1 (R1) is supposed to be assisted to shower once a week, but sometimes does not receive assistance for more than a week.

During the investigation, LPA interviewed staff and reviewed R1's file and documentation. According R1's assessment reviewed from July of 2025, R1 requires total dependence with bathing and has a difficulty understanding the need to take a few showers a week. Based on R1's current service plan dated September 12, 2025, R1 requests to have showers two times a week. In addition, service plan states staff remind R1 to take a shower almost every day but R1 always states he/she will tomorrow or ask for a male caregiver to assist, however when a male caregiver is available to assist, R1 refuses to shower. Based on shower logs and shift reports reviewed the past two months, it is documented that R1 was refusing showers when staff attempted to assist him/her or will shower once a week instead of twice a week. According to staff interviewed, R1 used to refuse showers in the past because he/she was weak and scared to be in the shower, however even though staff assured R1 that there will be two staff assisting, R1 still refused showers. In addition, interviewed staff indicated that R1 is now showering twice a week; Mondays and Thursdays.

Regarding the allegation, staff violated client's personal rights, according to the reporting party, staff (name unknown) said something disrespectful to R1 in another language and attempted to put hands on him/her. No further information is forthcoming.

During the investigation, LPA interviewed R1 and interviewed staff. According to staff interviewed, R1 has not mentioned anything about a staff saying something disrespectful to him/her or a staff attempting to put his/her hands on R1. The administrator indicated that there was an alleged incident that occurred last year and it has already been investigated. According to R1, the incident happened a year ago where Staff 1 (S1) was in the hallway and used profanity in a different language (not directly at R1), and when R1 yelled to S1 that he/she understood, S1 came into R1's room and pushed R1 in the chest lightly. No residents or other staff witnessed this incident. LPA interviewed S1, who indicated that he/she did not say anything disrespectful to R1 and never put his/her hands on S1. R1 stated that both him/her and S1 are really good friends now and there are no issues with S1. There is conflicting information between alleged staff and R1.

Based on interviews conducted, records reviewed, and observations, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with administrator and a copy is provided with appeal rights.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2025
LIC9099 (FAS) - (06/04)
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