Millbrae Board & Care Home

Type of visit: Required - 1 Year

On 03/04/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with licensee/Administrator Elena Madriaga. During today's visit there are 4 resident present and 3 staff. This is a two story facility. The facility is licensed for ages 60 and over. 5 may be non-ambulatory. Facility is cleared for 3 hospice residents and one bedridden resident. There are no hospice residents as of today's inspection. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. Residents only reside on the ground level of the facility. The upper level is the private dwelling of the licensee and family members associated to the facility. LPA observed the facility kitchen which is clean and appliances are in good repair. Knives are stored and locked in a lower cabinet in a bright orange tool box. Medications are observed to be locked in a cabinet as well in an area adjacent to the kitchen in between the garage and kitchen. Perishable and non-perishable food items are observed as in place. There is an additional freezer in the garage. Cleaning supplies are observed to be locked in the garage and below the kitchen sink. First aid kit is observed as complete with required items. LPA observed that there are multiple fire extinguishers in place last inspected 06/09/2025, smoke detectors, carbon monoxide detectors are observed in place through out the facility, facility smoke detectors are hard wired, and central heating system is functioning. Facility has full sprinkler system through out. Laundry area is also observed as fully operational in the garage. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Exit doors are labeled. Resident bathrooms are observed to be in good working order. Non-skid mats are in place in showers. Water temperature was measured at 106F in a common bathroom in the rear of the facility and at 113F in a resident bathroom. Continued on next page... Page 2 LPA observed resident rooms at random and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place. During today's visit LPA reviewed 4 resident files and 4 staff files of which all are current and includes health screenings for all staff. Resident medications are reviewed and are logged appropriately. Facility allows resident's to use licensee's phone for virtual or remote meeting of family members. Emergency keys are available for staff use. Last disaster drill conducted on 12/27/2025. Administrator certificate is current for Elena expiring 11/10/2026. The following updated forms are requested to be submitted to CCLD by 03/12/2025: • Copy of facility's liability insurance • LIC308 Designation of responsible staff person • LIC500 Staff Schedule • LIC610E Emergency Disaster Plan No citations are issued on this day. Report is reviewed with licensee/administrator Elena Madriaga.the state’s words, verbatim · CDSS document, Mar 4, 2026

Type of visit: Required - 1 Year

On 03/05/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with licensee/Administrator Elena Madriaga. During today's visit there are 4 resident present and 4 staff. LPA was allowed entry into the facility. This is a two story facility. The facility is licensed for ages 60 and over. 5 may be non-ambulatory. Facility is cleared for 3 hospice residents and one bedridden resident. There is 1 hospice resident as of today's inspection. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked in a lower cabinet in a bright orange tool box. Medications are observed to be locked in a cabinet as well in an area adjacent to the kitchen in between the garage and kitchen. Perishable and non-perishable food items are observed as in place. There is an additional freezer in the garage. Cleaning supplies are observed to be locked. First aid kit is observed as complete with required items. LPA observed that there are multiple fire extinguishers in place last inspected 06/12/2024, smoke detectors, carbon monoxide detectors are observed in place through out the facility, facility smoke detectors are hard wired, and central heating system is functioning. Facility has full sprinkler system through out. Laundry area is also observed as fully operational in the garage. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Exit doors are labeled. Resident bathrooms are observed to be in good working order. Non-skid mats are in place in showers. Water temperature was measured at 118F in a common bathroom in the rear of the facility and at 120F in a resident bathroom. LPA advised on monitoring the water temperature to ensure it does not exceed 120F. Continued on next page... Page 2 LPA observed resident rooms at random and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place. During today's visit LPA reviewed 4 resident files and 4 staff files of which all are current and includes health screenings for all staff. Facility does not handle resident monies. Resident medications are reviewed and are logged appropriately. Facility allows resident's to use licensee's phone for virtual or remote meeting of family members. Emergency keys are available for staff use. Last disaster drill conducted on 12/28/2024. Administrator certificate is current for Elena expiring 11/10/2026. The following updated forms are requested to be submitted to CCLD by 03/12/2025: • Copy of updated Administrator Certificates posted in facility. • 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 current lease No citations are issued on this day. Report is reviewed with licensee/administrator Elena Madriaga.the state’s words, verbatim · CDSS document, Mar 5, 2025

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds, including 2nd floor staff quarters and attached garage. Clients reside on ground floor, where there are 5 client bedrooms, staff room, 2 full bathrooms, 2 half bathrooms, kitchen, dining/living space and pantry. Upper level for staff consists of 2 bedrooms and bathroom. No accessible bodies of water or fire safety hazards are observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Liquid soap is available at all sinks. Hot water temperature is tested at 115 degrees in main bathroom. Food supply and first-aid kit are inspected. A Disaster and Mass Casualty Plan is posted. There are 5 residents present, and 4 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. Elena Madriaga is a certified RCFE administrator (x 11/24) that oversees facility operations. Client files are reviewed, including medications, which are recorded on Centrally Stored Medications Records. The following forms are requested to be updated and returned to CCL by 5/7/24: • LIC 308 Designation of Administrative Responsibility • LIC 500 Personnel Report • LIC 610D Emergency Disaster Plan (9 pages) • Proof of current liability insurance - Facility Sketch (including dimensions) No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed. See Advisory Notes--8 pages--for technical violations to be addressed.the state’s words, verbatim · CDSS document, Apr 23, 2024