Millbrae Paradise Care Home

Type of visit: Required - 1 Year

On 03/03/2026, Licensing program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection. LPA met with administrator Sophia Chen and explained the purpose of today’s visit. Currently there are 5 residents and 2 caregivers present, one being the administrator. 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 is one hospice resident. 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 sink where cleaning supplies are also locked. Toxic chemicals are stored in the garage primarily and observed as locked. Laundry area is in the garage and both the washer and dryer are operational on this day. PPE and incontinence supplies are observed to be in place. Medications are locked in the kitchen in a large upper cupboard. 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 130F in all three bathroom sinks. LPA observed the water heater that was recently serviced and it is turned down to its lowest setting. A fire extinguisher is observed in the kitchen with an inspection tag of 11/20/2024 but the dial indicates that the extinguisher is within the charged range. Continued on next page... Page 2 LPA observed resident linen supplies in closets as in place. 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 11/2025 per records reviewed. Administrator certificate is observed to be current posted in the facility expiring 08/14/2027. Required signs are posted in the facility. The following updated forms are being requested to be received by 03/10/2026: • Copy of updated administrator certificate • Copy of facility's liability insurance • LIC308 Designation of responsible staff person • LIC500 Staff Schedule There are no citations issued during today's inspection visit both advisories and technical violation is observed on this day on the attached LIC9102TA and LIC9102TV reports . Report is reviewed with Sophia and a copy is provided on this day.the state’s words, verbatim · CDSS document, Mar 3, 2026

Type of visit: Required - 1 Year

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 Continued on next page... Page 2 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.the state’s words, verbatim · CDSS document, Jan 16, 2025

Type of visit: Prelicensing

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. 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.the state’s words, verbatim · CDSS document, Feb 16, 2024

Type of visit: Office

COMP II by CAB successfully completed Method: Phone Call Applicant/administrator participated in COMP II at CAB telephone call with analyst at CAB. Identification of the applicant and administrator was verified by presenting photo ID via phone. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Jan 23, 2024