Millbrae Assisted Living Home

Type of visit: Case Management - Annual Continuation

To complete annual inspection of 12/3/25, LPA Jeung reviewed staff files--including training--and Centrally Stored Medications Records. Pharmacy prepares and delivers 7 day supply of prescribed medications in bubblepacks for each resident, for each day--for morning, noon, evening and bedtime doses, as well as providing Centrally Stored Medications Records. Based on staff training records available for review, it cannot be determined that staff have received required training. According to administrator, training records are being updated to reflect training received by each staff. Administrator agreed to submit staff training summaries to CCLD by 12/19/25, which will include online and in person training. All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. Deficiency of the California Code of Regulations, Title 22, is cited on a following page.the state’s words, verbatim · CDSS document, Dec 11, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(1) · Plan of correction due date: Dec 26, 2025

PERSONNEL REQUIREMENTS- GENL Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met, as first aid training cannot be verified for 4 out of 6 staff files reviewed. Licensee failed to ensure that care staff maintain valid first aid training, which poses a potential health or safety risk to clients in care. No current first aid training for staff #2, #4, #5, #6.the state’s words, verbatim · CDSS document, Dec 11, 2025

Plan of correction: Proof of current first aid training for S2, S4, S5, S6 will be sent to CCLD BY DUE DATE.

Type of visit: Required - 1 Year

LPA Jeung toured facility and grounds of this 2-story facility. There is one elevator and 2 stairwells, 7 shared rooms on ground floor and 17 shared rooms on second floor; all rooms have a private bathroom. On the ground floor, there are 2 offices, medication room, kitchen, living and dining rooms. On the second floor, there is a common TV room and laundry room. Medications are secured in medication room and toxins are secured in locked maintenance room on ground floor. Supplies of food preparation and service items, perishable and non-perishable foods, bed and bath linens and PPE are maintained. Hot water temperature tested randomly in first and second floor rooms within range of 105 and 120 degrees F. There is an emergency call system installed in each bedroom and bathroom, that transmits audible and visual signal to reception desk on ground floor, as well as to pagers carried by caregivers. Client files are reviewed. Mary Ann Lucero is a certified RCFE administrator (x10/27) that oversees facility. Staff records and medication records will be reviewed at a later date, due to time constraints. The following forms/information are requested to be submitted to CCLD BY 12/17/25: - Affidavit regarding Client Cash Resources (LIC400) - proof of current surety bonding, if applicable - Personnel Report (LIC500) - Hospice plan of operation Proof of current liability insurance is given to LPA today. Deficiencies of the California Code of Regulations, Title 22 are cited on following pages. See Advisory Notes for technical violations--2 pages.the state’s words, verbatim · CDSS document, Dec 3, 2025

Allegation investigated: Improper disposal of contaminated waste paper Client's hygiene needs are not met by staff Staff violated client's personal rights

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 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.the state’s words, verbatim · CDSS document, Nov 3, 2025 · control 14-AS-20251003123635

Allegation investigated: - Staff person touched residents in a sexual manner

Licensing Program Analyst (LPA) Audrey Jeung met with administrtaor and explained the purpose of today’s visit. During the course of the investigation, the Department conducted multiple interviews, reviewed documents, and worked with other outside agencies such as law enforcement and District Attorneys office to reach the findings. Based on interviews with the alleged victims, no one conclusively indicated that S1 sexually touched a resident, but alleged other actions such as kissing a resident on his/her cheek. No resident or the suspected abuser admitted to touching a resident in a sexual manner. Based on these observations, this allegation is determined to be UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore the above allegation is unsubstantiated at this time. This report is reviewed with Ms. Lucero and a copy is provided during today's visit. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 26, 2025 · control 14-AS-20250417165434

Allegation investigated: - Staff sexually abused resident

Licensing Program Analyst (LPA) Audrey Jeung met with administrator and explained the purpose of today’s visit. During the course of the investigation, the Department conducted multiple interviews, reviewed documents, and worked with outside agencies such as law enforcement and District Attorneys office to reach the findings. Based on interviews with the alleged resident and the suspected staff person, there were conflicting reports of what may have happened. No residents or other staff witnessed any sexual abuse. An involved outside agency offered a sexual assault exam, which the resident declined. The resident also indicated that they wanted to "drop it" and didn't want to press charges against the alleged staff. Due to the conflicting reports and no evidence of sexual abuse the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore the above allegation is unsubstantiated at this time. This report is reviewed with Ms. Lucero and a copy is provided during today's visit. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 26, 2025 · control 14-AS-20250616144837

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Audrey Jeung met with administrator and explained the purpose of today's case management visit related to complaint control #14-AS-20250417165434. During the course of a complaint investigation of the allegation under complaint control #14-AS-20250417165434 alleging "Staff person touched residents in a sexual manner," it was discovered that the facility did not report the suspected sexual abuse to the Department at any time but did report to other outside agencies. This poses an immediate health and safety risk to residents in care. Citation issued on the following LIC809D Report is reviewed with Ms. Lucero and a copy is provided on this day.the state’s words, verbatim · CDSS document, Aug 26, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(b) · Plan of correction due date: Aug 27, 2025

REPORTING REQUIREMENTS Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, & the local law enforcement agency within 2 hours as required by WIC Section 15630(b)(1). This requirement was not met as the facility did not report the suspected sexual to the Department, based on interviews and documentation reviewed.. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 26, 2025

Plan of correction: Plan of correction to be submitted to CCLD in writing indicating that all incidents regarding sexual abuse will be reported to the Department within 2 hours regardless if the allegation is under investigation by the facility or other agencies.

Type of visit: Required - 1 Year

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. Continued on next... Page 2 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.the state’s words, verbatim · CDSS document, Oct 8, 2024

Type of visit: Case Management - Other

On 02/06/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - other visit in order to deliver the exclusion letter of a staff person associated to the facility. LPA met with Resident care coordinator - Alex Manalo and Chief operating officer - Jason Mullen and explained the purpose of today's visit. LPA explained the letter and what it is indicating regarding the staff person and he is no longer able to work in the facility or come in contact with residents in care. According to staff Alex and Jason, the staff person being excluded hasn't contacted the facility, or worked in the facility since September 2023 and has not been on the schedule since then. Letter is hand delivered to Jason Mullen and report is reviewed with both staff persons.the state’s words, verbatim · CDSS document, Feb 6, 2024