Cadence Millbrae.
Cadence Millbrae is Ranked in the top 48% of California memory care with 6 CDSS citations on record; last inspected Nov 2025.
A large home, reviewed on public record.
Compared to 115 California facilities with a similar number of beds.
RCFE · 36-month window. Higher percentile = better performance on inspection record. Source: California Dept. of Social Services · Community Care Licensing.
among peers to rank.
Rankings based on 36-month CDSS inspection data. Severity and frequency: fewer citations = higher percentile. Repeat rate: lower repeat citation share = higher percentile.
FACILITY WATCH · BETA
Cadence Millbrae has 6 citations on record. Know the moment anything changes.
New findings, complaint investigations, or status changes — emailed to you free.
Citation history, plotted month by month.
6 deficiencies on record. Each bar is a month with a citation.
Finding distribution
5 total · 36 monthsScope × Severity (CMS A–L)
The rules that apply to this facility.
State requirements with the exact regulation citation, plain-language explanation, and a question to ask on tour. Rules this facility has been cited for appear first.
Plain language
Because a facility markets dementia or Alzheimer's care, state law mandates higher training standards: 12 hours of initial dementia training (6 hours before a staff member works independently with residents, 6 more within the first 4 weeks), 8 hours of annual dementia in-service every year thereafter, and an administrator must include 8 hours of dementia-specific continuing education in every 2-year recertification cycle. Training must cover individualized care plans, behavioral expressions, appropriate supervision, and the facility's dementia care philosophy.
Ask on tour
“Can you show me each direct-care staffer's most recent dementia training certificate, and tell me when their next refresher is due?”
Questions to ask before you visit.
A short pre-tour checklist tailored to Cadence Millbrae's record and state requirements.
The facility has 7 serious citations on file across all inspections — can you provide your corrective-action plan for each cited item, and show families any documentation of remediation steps taken?
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11 complaints are on file with CDSS — were any substantiated, and what remediation did the facility take in response to substantiated findings?
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The most recent inspection on 2025-11-25 found deficiencies — can you provide the deficiency notice from that visit and walk families through the specific corrective actions you implemented?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Every inspection visit, verbatim.
13 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2025-11-25Annual Compliance VisitType A · 1 finding
Plain-language summary
On November 25, 2025, inspectors investigated an incident from October 29, 2025, in which a staff member pulled a resident's hair when the resident fell from their wheelchair; the facility's security camera confirmed this happened, and the staff member left the facility on November 4, 2025. The resident showed no signs of injury and did not require hospitalization, but the facility was cited for failing to protect the resident's rights and safety. The facility terminated the staff member's employment.
“Based on interviewes conducted, and incident report recieved, it was confirmed that the med-tech on duty was observed to pull the hair of a resident. This was witnessed by another staff on duty. This was reported to facility leadership and camera footage was reviewed confirming the abuse. This poses an immediate health and safety risk to resident in care.”
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On 11/25/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - incident report visit. LPA met with the executive director Holly Suiter and explained the purpose of today's visit. On 11/14/2025 the Department received an incident report regarding a resident that was observed to be abused by a med-tech on duty. The resident slid from their wheelchair and the med-tech pulled the resident's hair as the resident was on the floor. This abuse was caught on camera and was brought to the attention of the business office director on 11/03/2025 by another caregiver that witnessed the abuse. The hair pulling took place on 10/29/2025 and was caught on camera. Facility leadership reviewed the camera footage and confirmed the staff person's action via the footage. Facility leadership, the administrator and business office director, met with the staff person and addressed the incident observed via camera footage. The staff person denied the allegation despite the camera footage evidence and left their position as med-tech voluntarily on 11/04/2025. The facility terminated the med-tech and has not returned to the facility for work duties since 11/04/2025. Due to the age of the incident, there is no signs of injury to the resident. The resident resides in the memory care portion of the facility. An assessment of the resident was conducted and there were no visible signs of injury. The resident was not sent to the hospital. The facility is being cited for personal rights due to the med-tech's abuse as it is an immediate health and safety concern for the resident in care. Citation issued on the following LIC809D. Report is discussed and a copy is provided to the executive director.
2025-08-27Other VisitNo findings
Plain-language summary
On August 27, 2025, state licensing conducted a routine unannounced inspection of this 157-bed facility (136 in assisted living, 21 in memory care) and found no violations. The inspector toured the building and reviewed medications, staff files, resident rooms, safety equipment, and training records, all of which were in order; the facility was asked to submit updated copies of its liability insurance, emergency plan, and staff schedule by early September. The facility has current administrator certification, secured memory care areas, and emergency protocols including a drill conducted in May 2025.
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On 08/27/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with the executive director Holly Suiter and explained the purpose of today's visit. There are currently 136 residents in assisted living and 21 in memory care. This is a multi-level facility approved for all residents allowed to be non-ambulatory, five bedridden, and a hospice clearance for 14 residents. This facility does have a secured memory care area. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked and secured in the kitchen. Perishable and non-perishable food supplies are observed as in place. Kitchen grade fire extinguisher is observed as in place and with an inspection date of 06/08/2024. First aid kit is observed as complete with required items as observed in medication room. Medications are observed to be locked in cabinets and medication cart in the medication room. LPA reviewed resident medications at random and observed them as current. LPA observed that there are multiple fire extinguishers in place on each floor with an inspection date of 07/07/2025 smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating and air conditioning. Laundry areas are also observed as fully operational. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted in May 2025. Water temperature was measured at 108F in resident rooms at random and 111F in a common bathroom. Cleaning supplies are observed to be inaccessible to residents in care. Resident rooms are observed at random. LPA observed two resident rooms and both appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Continued on next page... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Page 2 Resident linen supplies are observed as in place. LPA reviewed five staff files and five resident files during today's inspection and all files are observed as current. Staff are actively conducting training via Relias and it is observed as current. Administrator certificate is current expiring 01/14/2027. The following updated forms are requested to be submitted to CCLD by 09/03/2025 : • Copy of facility's liability insurance • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule No citations issued. Report is reviewed with Holly and a copy is provided on this day.
2025-08-27Complaint InvestigationUnsubstantiatedNo findings
2025-04-08Complaint InvestigationUnsubstantiatedNo findings
2024-11-08Annual Compliance VisitNo findings
Plain-language summary
On November 8, 2024, state licensing conducted an unannounced investigation following a report of a concerning incident involving a resident. The facility investigated but could not identify the person described by the resident, and no staff or other residents matched the description provided. To address the resident's concerns, the facility implemented precautions including assigning female-only staff to the resident and having any male staff accompanied by a female care partner, and no violations were found.
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On 11/08/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - incident visit in response to an SOC 341 report received on 11/07/2024. LPA met with administrator Joan Newman and explained the purpose of today's visit. During today's visit LPA conducted interviews and collected pertinent documents regarding the resident. LPA also discussed the incident with the local long term care ombudsman assigned to this facility regarding the incident. Facility staff investigated the reported incident but could not come to any conclusions. The person in question as described by the resident, could not be a staff member as there are no staff matching the description of the supposed person. Male residents in the area also do not match the description provided. Facility does not have cameras in common areas of the facility. Per the facility the incident was reported to the hospice agency who then reported to the facility. As a precaution the facility has implemented a plan to assist the resident in order to prevent any issues in regards to males entering the resident's room. The facility has assigned no male staff to the resident, but if there is a male med-tech needs to visit the resident, they are to be accompanied a female care partner. The facility met with the family and they are aware and are working with the facility at this time. No further issues were discussed. No citations issued.
2024-11-08Complaint InvestigationSubstantiatedType A · 1 finding
“Based on interviews and documentation reviewed, LPA discovered that the medication was prescribed for the duration of 2024 but was stopped on two spans of time from 2/18/24 through 04/07/24 and 04/27/24 through 08/17/24 without documentation on file from the physician of the resident to discontinue.”
2024-09-27Other VisitType B · 1 finding
Plain-language summary
On September 27, 2024, the state conducted an unannounced visit to follow up on a 2023 complaint and found that the facility could not produce required documentation about a resident's daily care activities from June 2023. The missing record posed a potential health and safety risk, and the facility received a citation for the failure to maintain this documentation.
“Based on recrod request, the facility is unable to provide a resident document dated 06/27/2023 that should be maintained for 3 years following the termination of service to the resident.”
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On 09/27/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - other visit. LPA met with Tina Pedagat Business Office Manager and explained the purpose of today's visit. During today's visit LPA Vado is requesting documentation related to complaint # 14-AS-20230804102303 regarding a resident in care at the time of the complaint investigation in 2023. LPA requested the date specific document but the facility does not have the requested record to provide to the Department regarding R1's ADL reference sheet from 06/27/2023. This poses a potential health and safety risk to residents in care. Due to the facility not having this document not being able to be found a citation is issued on this day. Citation issued on the attached LIC809D. Report is reviewed with Tina Pedagat and a copy is provided during on this day.
2024-08-20Other VisitNo findings
Plain-language summary
On August 20, 2024, inspectors conducted a routine unannounced annual inspection of this 108-bed facility (91 in assisted living, 17 in memory care) and found no violations. The inspection covered safety systems including fire extinguishers, smoke and carbon monoxide detectors, emergency exits, kitchen operations, medication storage, resident rooms, and staff and resident files—all of which met requirements. The facility was asked to submit several routine updated documents by late August.
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On 08/20/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with the executive director Joan Newman and explained the purpose of today's visit. There are currently 91 residents in assisted living and 17 in memory care. LPA was allowed entry into the facility. This is a multi-level facility approved for all residents allowed to be non-ambulatory, five bedridden, and a hospice clearance for 14 residents. This facility does have a secured memory care area. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked and secured in the kitchen. Perishable and non-perishable food supplies are observed as in place. Kitchen grade fire extinguisher is observed as in place and with an inspection date of 06/08/2024. First aid kit is observed as complete with required items as observed in medication room. Medications are observed to be locked in cabinets and medication cart in the medication room. LPA reviewed resident medications at random and observed them as current. LPA observed that there are multiple fire extinguishers in place on each floor with an inspection date of 06/12/2024, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating and air conditioning. Laundry areas are also observed as fully operational. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 08/07/2024. Water temperature was measured at 111F in resident rooms at random. Cleaning supplies are observed to be inaccessible to residents in care. Resident rooms are observed at random. LPA observed five resident rooms and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Continued on next page... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Page 2 Resident linen supplies are observed as in place. P&I monies are not handled by the facility. LPA reviewed four staff files and five resident files during today's inspection and all files are observed as current. Staff conducting via Relias and observed as current. Administrator certificate is current expiring 02/28/2025. The following updated forms are requested to be submitted to CCLD by 08/27/2024 : • Copy of updated Administrator Certificate • Copy of facility's liability insurance • LIC400 Affidavit Regarding Client/Resident Cash Resources • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule • Copy of control of property or copy of lease No citations issued. Report is reviewed with Joan and a copy is provided on this day.
2024-06-24Other VisitNo findings
Plain-language summary
On June 24, 2024, state regulators met with facility leadership to discuss violations found in prior inspections, including failures in resident rights protection, infection control, incident reporting, resident monitoring, basic services, and care reassessments. The facility agreed to a compliance plan and will receive unannounced inspections every few months for the next two years to verify that improvements have been made. The state provided the facility with resources to help improve operations.
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On 6/24/24, San Bruno Regional Office conducted a non-compliance conference meeting with Executive Director, Joan Newman, Attorney Joel Goldman, Regional VPO Mark Maclaine, Director of Compliance Holly McMurry. Present in the meeting was Regional Manager, Vivien Helbling, Licensing Program Manager, April Cowan, and Licensing Program Analyst, Grace Donato. During non-compliance meeting, the following violations were discussed, 87468.1(a)(2) Personal Rights of Residents in All Facilities, 87470(b)(2) - Infection Control Requirements, 87211(a)(2) - Reporting Requirements, 87466 - Observation of Resident, 87464 - Basic Services, 87468.2(a)(4) - Additional Personal Rights of Residents in Privately Operated Facilities, 87463(a)(4) - Reappraisals. During this meeting, it was discussed, Licensee will receive more frequent monitoring inspection visits to ensure compliance with this compliance plan and Title 22 Regulations for 2 years. Licensee was provided the link below for resources and guidance to improve facility operations: https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers
2024-05-08Complaint InvestigationUnsubstantiatedNo findings
2024-03-01Complaint InvestigationSubstantiatedType A · 2 findings
“Based on the investigation the facility failed to reassess resident who was identified as a fall risk and develop a plan of care to prevent falls and meet the resident's needs.”
“Based on the investigaiton the facility did not provide care and supervision to meet the needs of a resident who was identified as a fall risk and suffered a fall on May 29, 2023 that resulted in arm separation. There was no staff to supervise and was no where to be found.”
2024-02-22Complaint InvestigationSubstantiatedCitation on file
Plain-language summary
An investigation found that a resident fell without staff supervision in May 2023 and sustained a shoulder separation requiring hospitalization. In June 2023, the resident was hospitalized with severe dehydration, high blood sugar, and sepsis after missing meals; staff failed to document the change in his condition or report it to family and medical providers. The facility was cited for inadequate basic services and failure to properly observe the resident, with civil penalties of $1,000 imposed.
Substantiated — the state found a violation and issued a citation. Full citation details are on file with the state.
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According to facility records, several falls were documented--in March 2022, February 2023, April 2023. Client did not sustain any significant injuries as a result of these falls; he was evaluated at the hospital after April 2023 fall and released the same day. Client was not under direct staff supervision on 5/29/23 when he fell in the common living room of memory care unit and sustained an acute shoulder separation. Client was evaluated and treated at the hospital. On 6/27/23, client was observed to be unresponsive with low oxygen level. 9-1-1 was called and client was transported to hospital, where tests revealed he was severely dehydrated and significantly hyperglycemic. Client was admitted to ICU with severe sepsis and hypernatremia. Based on staff interviews, client missed 3 meals immediately prior to hospitalization, only one of which was documented. In addition, client was known to be always eager to eat, so his refusal to eat was unusual. Staff failed to accurately document the change in condition. report this to client's family and seek medical advice. Deficiencies of the California Code of REgulations, Title 22 are cited on a following page, as well as civil penalties of $1000-- $500 for Section 87464 Basic Services and $500 for Section 87466 Observation of Resident. Assessment of additional civil penalties is pending.
2023-08-03Other VisitNo findings
Plain-language summary
During a meeting to review the facility's organizational changes, inspectors found that the facility changed ownership when it was acquired by Cogir Management USA Inc. in November 2022, but the facility did not apply for a new license under the new owner as required by state law. The state cited a violation because the facility continued operating under the previous owner's license instead of obtaining a new one.
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LPA Jeung met with executive director in response to facility's organizational changes. RCFE Disclosure Worksheet (LIC606)--including organization chart--was submitted to CCLD, which identifies Cogir Management USA Inc. as licensee/co-licensee. According to Administrative Organization (LIC309), 9388-0045 Quebec Inc. owns 100% interest, and is the parent company of Cogir Management USA Inc. Cadence Senior Living, LLC no longer holds ownership interest in this facility, as it was acquired by Cogir, as per information on Cogir website dated November 2022. RCFE license was issued to licensee 1201 Operator-LLC/Cadence SL Millbrae LLC,, with Cadence as the management company. Since Cadence was acquired by Cogir, and is now managing the facility, the entity that is now operating the facility is required to apply for RCFE licensure. Deficiency of the California Code of Regulations, Title 22, is cited on a following page.
9 older inspections from 2021 are not shown in the free view.
9 older inspections from 2021 are not shown in the free view.
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