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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601170
Report Date: 01/16/2025
Date Signed: 01/16/2025 01:33:34 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/16/2025 01:33 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 PARADISE CARE HOMEFACILITY NUMBER:
415601170
ADMINISTRATOR/
DIRECTOR:		CHEN, SOPHIAFACILITY TYPE:
740
ADDRESS:514 ANITA LANETELEPHONE:
(650) 697-2201
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY: 6CENSUS: 6DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administrator - Sophia ChenTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 01/16/2024, Licensing program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection. LPA met with Caregiver Siliilani Leleivuna and explained the purpose of today’s visit. Currently there are 6 residents and 2 caregivers present. During the visit caregiver called the administrator to inform her of LPAs presence. During the visit the administrator Sophia Chen arrived and met with LPA.

This is a single level facility with 6 bedrooms for residents. The facility is licensed for age 60 and over. 6 non-ambulatory. Hospice waiver granted for 3 residents. Currently there are no hospice residents. LPA Vado toured the facility both inside and outside. All outdoor and indoor passageway are free and clear of obstructions for emergency exit routes in case of fire or emergency. Facility's ambient temperature is comfortable for residents and LPA. No pools or bodies of water were observed during today's visit on the premises. LPA observed fresh food supplies and emergency one week of nonperishable and two (2) days of perishable foods as in place. There is a freezer located in the garage and a full refrigerator and freezer in the kitchen. Canned food supplies are primarily observed as stored in the garage. Knives are locked in the kitchen in a drawer and below the sing cleaning supplies are locked. Toxic chemicals are stored in the garage primarily. Cleaning supplies and laundry soaps are also locked in the garage. Laundry area is in the garage and both the washer and dryer are operational. PPE and incontinence supplies are observed to be in place. Medications are locked in the kitchen in a large upper cubbard. Each resident room is observed to contain the required furniture as outlined in regulations. Facility has functioning smoke detectors and carbon monoxide detectors through out the facility. LPA Observed a fire pull station located at the front of the facility near the front door. The facility is equipped with 2.5 bathrooms. Room 3 contains its own half bath. There are two other full bathrooms with showers in the facility. All are observed in good working order for resident use. Water temperature is tested at 110F in all three bathroom sinks. There are three fire extinguishers in the facility that is observed with inspection tags of 11/20/2024

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SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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 PARADISE CARE HOME
FACILITY NUMBER: 415601170
VISIT DATE: 01/16/2025
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LPA observed resident linen supplies in closets. All tubs/shower floors are equipped with non-skid mats when in use. Based on review of all resident files, and medications all items are current and logged accurately. Last fire/disaster drill was conducted on 10/17/2024 per records reviewed. Administrator certificate is observed to be current posted in the facility expiring 08/14/2025. Required signs are posted in the facility.

The following updated forms are being requested to be received by 01/23/2025:

• Copy of updated administrator certificate
• 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 inspection visit. Report is reviewed with Sophia and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
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