Millbrae Family Care Home

Type of visit: Required - 1 Year

On 08/26/2026, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with administrator Wilma Deguzman. There are currently 3 residents in the facility and 2 staff present. This is a single level facility licensed for residents age range of 60 years and over all of which may be non-ambulatory. License is approved for 3 hospice residents. During the inspection there are no hospice residents present but was informed that a hospice resident will be moving in later today. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. 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 in kitchen drawer adjacent to the stove. Perishable and non-perishable food items are observed as in place. There is an additional refrigerator and freezer in the garage area which carries additional food supplies for resident use. First aid kit is observed as complete with required items. Medications are observed to be locked in the kitchen in a lockable cabinet. LPA observed that there are two fire extinguishers in place which are currently within operating range, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating. PPE is observed to be in place stored in a closet within a resident bathroom. 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. Last emergency/disaster drill was conducted on 07/18/2026. According to administrator they are conducting soon due to facility improvements such as solar and fence repair. Water temperature was measured at 111F. Cleaning supplies are observed to be locked in beneath the kitchen sink and additional toxins and cleaning supplies are observed to be locked in the garage. Continued on next... Page 2 LPA observed all resident rooms and all are observed as clean, free of odors, and contained all the required furniture per regulatory recommendations. Extra resident linen supplies are observed as in place in hallway closets. There are two resident full bathrooms, and a half bath in room 3, all are observed which are in good repair. Shower floors are equipped with non-skid mats. Medications and logs are observed today as current. During today's inspection LPA reviewed 3 resident files which are current and 3 staff files which are current. Administrator certificate is observed as current expiring 05/21/2028 for Wilma De Guzman. The following updated forms are requested to be submitted to CCLD by 09/02/2026: • Copy of updated administrator certificates as there are more than one administrator • Copy of facility's liability insurance • LIC308 Designation of responsible staff person • LIC500 Staff Schedule Report is reviewed with Wilma and a copy of the report is provided on this day.the state’s words, verbatim · CDSS document, Aug 26, 2026

Type of visit: Required - 1 Year

On 08/27/2024, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with administrator Wilma Deguzman. There are currently 5 residents in the facility and one resident is out of the facility with family. This is a single level facility licensed for residents age range of 60 years and over all of which may be non-ambulatory. License is approved for 3 hospice residents. There is 1 hospice resident as of today's inspection visit. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. The rear fence of the facility has been replaced and repaired based on observations made. 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 in kitchen drawer adjacent to the stove. Perishable and non-perishable food items are observed as in place. There is an additional refrigerator and freezer in the garage area which carries additional food supplies for resident use. First aid kit is observed as complete with required items. Medications are observed to be locked in the kitchen in a lockable cabinet. LPA observed that there are two fire extinguishers in place which are currently within operating range, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating. PPE is observed to be in place stored in a closet within a resident bathroom. 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. Last emergency/disaster drill was conducted on 08/27/2024. According to administrator they are conducting soon due to facility improvements such as solar and fence repair. Water temperature was measured at 109F. Cleaning supplies are observed to be locked in beneath the kitchen sink and additional toxins and cleaning supplies are observed to be locked in the garage. Continued on next... Page 2 LPA observed all resident rooms and all are observed as clean, free of odors, and contained all the required furniture per regulatory recommendations. Extra resident linen supplies are observed as in place in hallway closets. There are two resident full bathrooms, and a half bath in room 3, all are observed which are in good repair. Shower floors are equipped with non-skid mats. Medications and logs are observed today as current. During today's inspection LPA reviewed 4 resident files which are current and 3 staff files which are current. Administrator certificate is observed as current expiring 05/21/2026 for Wilma De Guzman. The following updated forms are requested to be submitted to CCLD by 07/29/2025: • Copy of updated administrator certificates as there are more than one administrator • 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 Report is reviewed with Wilma and a copy is provided on this day. Citation issued on following LIC80D and Technical Violation on the following LIC9102TV.the state’s words, verbatim · CDSS document, Jul 22, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(c) · Plan of correction due date: Aug 1, 2025

§1569.695 Emergency Plans(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is notrequired during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This health and safety code has not been met as evidenced by: Based on documentation reviewed, LPA observed that there is no disaster drill log present. Per interviews with staff, a disaster drill has not been conducted in about a year. This poses an immediate health and safety risk to residents and staff in the facility.the state’s words, verbatim · CDSS document, Jul 22, 2025

Plan of correction: Facility shall conduct a drill and send evidence of it taking place along with the name of attendees and topic of the drill.

Type of visit: Required - 1 Year

On 08/27/2024, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with administrator Wilma Deguzman. There are currently 5 residents in the facility and one resident is out of the facility with family. This is a single level facility licensed for residents age range of 60 years and over all of which may be non-ambulatory. License is approved for 3 hospice residents. There is 1 hospice resident as of today's inspection visit. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. 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 in kitchen drawer adjacent to the stove. Perishable and non-perishable food items are observed as in place. There is an additional refrigerator and freezer in the garage area which carries additional food supplies for resident use. First aid kit is observed as complete with required items. Medications are observed to be locked in the kitchen in a lockable cabinet. LPA observed that there are two fire extinguishers in place which are currently within operating range, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating. Facility is not equipped with fire sprinklers. PPE is observed to be in place stored in a closet within a resident bathroom. 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. Last emergency/disaster drill was conducted on 08/27/2024. Water temperature was measured at 107F. Cleaning supplies are observed to be locked in beneath the kitchen sink and additional toxins and cleaning supplies are observed to be locked in the garage. Continued on next... Page 2 LPA observed all resident rooms and all are observed as clean, free of odors, and contained all the required furniture per regulatory recommendations. Extra resident linen supplies are observed as in place in hallway closets. There are two resident full bathrooms, and a half bath in room 3, all are observed which are in good repair. Shower floors are equipped with non-skid mats. Facility does not handle resident monies. Medications and logs are observed today as current. During today's inspection LPA reviewed 4 resident files which are current and 3 staff files which are current. Administrator certificate is observed as expired on 05/2024 but currently shows as pending online and payment has been received. The following updated forms are requested to be submitted to CCLD by 09/03/2024: • Copy of updated administrator certificates as there are more than one administrator • 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 No citations issued on this day. Report is reviewed with Wilma and a copy is provided on this day.the state’s words, verbatim · CDSS document, Aug 27, 2024

Type of visit: Case Management - Annual Continuation

LPA Jeung reviewed staff training records and client records--including medications--to complete annual inspection of 7/12/23. Deficiencies of the California Code of Regulations, Title 22, are cited on a following page.the state’s words, verbatim · CDSS document, Nov 21, 2023