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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601170
Report Date: 02/16/2024
Date Signed: 02/16/2024 06:27:22 PM


Document Has Been Signed on 02/16/2024 06:27 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:MILLBRAE PARADISE CARE HOMEFACILITY NUMBER:
415601170
ADMINISTRATOR:CHEN, SOPHIAFACILITY TYPE:
740
ADDRESS:514 ANITA LANETELEPHONE:
(650) 697-2201
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY:6CENSUS: 5DATE:
02/16/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Lani Leleivuna, Miriana Saric, Sophia ChenTIME COMPLETED:
06:30 PM
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Applicant SZB LLC has applied for RCFE licensure for 6 non-ambulatory elderly clients over age 59 in 6 rooms. Fire clearance has been approved. Facility is currently licensed and operating under the name Millbrae Paradise Retirement Home #410508755, which is reflected on application (LIC200). There are 5 residents present; no one is receiving hospice care.

LPA Jeung toured facility and grounds of this one level facility. There are 6 private bedrooms--one with private half bathroom--staff room, 2 full bathrooms, living room, dining room, and kitchen. There are 2 beds in staff room. Clothes washer and dryer are located in 2-car garage.
The backyard is level, fenced and mostly paved, and there are 2 detached storage sheds. Medications and toxins are secured in locked cabinets in kitchen and garage, respectively. Hot water temperature is tested at 105 degrees in front bathroom. Food preparation and service items are present, as well as perishable and non-perishable fruits vegetables and protein. Supplies of bed and bath linens and hygiene products are observed. Sophia Chen is a certified administrator (x8/25).

The following items are observed and must be addressed prior to licensure:

1. An internet access device dedicated for resident use--such as a computer, smart phone, tablet, or other device that can support real-time interactive applications, equipped with videoconferencing technology, including microphone and camera functions--must be maintained. (HSC 1569.319)
2. A set of keys--including all resident units, facility vehicles, all exit doors, all cabinets, cupboards or files that contain elements of the emergency and disaster plan, including, but not limited to, food supplies and protective shelter supplies--must be available to staff on each shift for use during an evacuation. (1569.695)
3. Emergency Disaster Plan (LIC610E) must be updated to include corrected utility shut off and fire extinguisher locations. (Section 87212 Emergency Disaster Plan)

LPA to be contacted upon completion of the above 3 items.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: MILLBRAE PARADISE CARE HOME
FACILITY NUMBER: 415601170
VISIT DATE: 02/16/2024
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Facility phone number is verified: 650/697-2201.

Applicant shall not retain bedridden persons, as there is no fire clearance approval for bedridden residents. Client #5 is bedridden, per MD report.

Component III RCFE orientation is reviewed with licensee/administrator Sophia Chen.

RCFE licensure is pending at this time.


SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024
LIC809 (FAS) - (06/04)
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