Hearts at Millwood Assisted Living
RCFE · Memory Care
A Residential Care Facility for the Elderly (RCFE) is a non-medical residential care home licensed by California CDSS under Health & Safety Code §1560. Residents receive help with daily living activities such as bathing, dressing, and medication management. An RCFE with a Memory Care designation is additionally required by California Title 22 (§87705 and §87706) to provide specialized staff training in dementia care, individualized care plans for residents with cognitive impairment, and appropriate supervision protocols — requirements that go beyond a standard RCFE license.
416 Millwood Dr · Millbrae, 94030
Quick facts
Quality snapshot
Updated April 25, 2026Compared to 182 California RCFE memory care facilities of similar size, over the last 36 months.
Source: California Department of Social Services, Community Care Licensing Division. View raw inspection records →
Quality grade· click to show how this was calculated
Severity66thWeighted citations per bed
Repeats100thRepeat deficiencies as share of total
Frequency65thDeficiencies per inspection
Tick mark at 50% = peer median · higher percentile = better facility
Quality grade· click to show how this was calculated
Weighted citations per bed
Repeat deficiencies as share of total
Deficiencies per inspection
Tick mark at 50% = peer median · higher percentile = better facility
Hearts at Millwood Assisted Living scores B. Better than 77% of comparable California RESIDENTIAL CARE ELDERLY facilities. Severity: 66th percentile. Repeats: top 0%. Frequency: 65th percentile.
Each metric is converted to a 0–100 percentile within the peer set (higher = better). The composite grade averages all four. Peer set: CA / rcfe_memory_care / small beds (182 facilities).
Citation severity over time
↓ improvingWeighted severity score per month · 24 months
Weighted score (24mo)
6
Last citation
Jun 24
Finding distribution
6 total · 36 monthsScope × Severity (CMS A–L)
The rules that apply to this facility
California Title 22 requirements for this facility, with the specific regulation and a suggested question for each.Rules this facility has been cited for are shown first.
What dementia-care training must staff complete?Cited Jun 202322 CCR §87705 / HSC §1569.625
Because this facility markets dementia or Alzheimer's care, state law mandates higher training standards:
- 12 hours initial dementia training — 6 hours before a staff member works independently with residents, 6 more within the first 4 weeks.
- 8 hours annual dementia in-service — required every year thereafter.
- Administrator CE — the 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: Ask how dementia training records are kept — families may request documentation.
How many staff must be on duty overnight?22 CCR §87415
Based on 6 licensed beds:
One qualified staff member must be on call and physically on premises at all times overnight.
Violation pattern to watch for:A facility that documents a staff member as "on call" but with that person physically off-site — when the law requires on-premises presence — is in violation of this section.
Ask on tour: Ask the facility to walk you through their overnight staffing plan and confirm whether on-call staff are on premises or off-site.
What health conditions can this facility legally accept or refuse?22 CCR §87612–87615
Restricted — allowed with physician order + care plan
- Supplemental oxygen
- Insulin and injectable medications
- Indwelling or intermittent catheters
- Colostomy / ileostomy
- Stage 1 and Stage 2 pressure injuries
- Wound care (non-complex)
- Incontinence
- Contractures
Prohibited — facility must refuse or discharge
- Stage 3 or Stage 4 pressure injuries
- Feeding tubes (PEG, NG, or J-tube)
- Tracheostomies
- Active MRSA or communicable infections requiring isolation
- 24-hour skilled nursing needs
- Total ADL dependence with inability to communicate needs
A hospice waiver (HSC §1569.73) can allow continued care for residents on hospice who would otherwise fall into a prohibited category.
Ask on tour: Ask whether your loved one's specific care needs are restricted or prohibited, and what the facility's process is if needs change after admission.
What must this facility report to the state — and how fast?22 CCR §87211 / WIC §15630
- ImmediateElopement, fire, epidemic outbreak, or poisoningImmediately
- 2 hoursAbuse with serious bodily injury2-hour phone report + 2-hour written report — to the California Department of Social Services (CDSS), Adult Protective Services, and law enforcement
- 24 hrsAbuse without serious bodily injuryWithin 24 hours
- Next dayDeath of a residentPhone by next working day; written within 7 days
- Next dayInjury requiring medical treatment beyond first aidPhone by next working day; written within 7 days
- WrittenBankruptcy, foreclosure, eviction, or utility shutoff noticeWritten notice to CDSS and residents — $100/day penalty (max $2,000) for failure
Your enforcement lever:Incidents that aren't reported on time are themselves a separate violation. If you believe a reportable event wasn't filed, you can submit a complaint directly to the California Department of Social Services (CDSS).
How does CDSS enforce these rules?22 CCR §87755–87777 / HSC §1569.58
- 1Notice of DeficiencyWritten citation with a correction deadline. Facility must submit a Plan of Correction.
- 2Civil PenaltyStarts at $50/day for non-serious; $150/day for serious deficiencies — immediately, with no grace period. Repeats escalate to $150 first day + $50/day, then $1,000 first day + $100/day.
- 3Suspension of AdmissionsFacility cannot accept new residents until violations are corrected.
- 4Temporary Suspension or RevocationEmergency suspension for imminent danger; full revocation after administrative hearing.
- 5Exclusion OrderAdministrator and operator can be barred from all CDSS-licensed facilities — not just this one.
See how these rules have been applied to this specific facility:
View state inspection record and citationsState records
California Dept. of Social Services · Community Care Licensing- License number
- 415601085
- License type
- RESIDENTIAL CARE ELDERLY
- License status
- LICENSED
- License expires
- Not yet indexed
- Licensed beds
- 6
- Operator
- Hearts at Millwood Rcfe Inc
Inspections & citations
9
reports on file
7
total deficiencies
1
Type A (actual harm)
1
dementia-care citations
Other visitApril 8, 2026No deficiencies
Plain-language summary
On April 8, 2026, a pre-licensing inspection visit was conducted at this facility while it was preparing to open or change its operations. The inspector met with the administrator and found no violations during the inspection.
View full inspector notes
On 04/08/2026, Licensing program Analyst (LPA) Jaime Vado conducted an announced prelicensing inspection visit. LPA met with Administrator/Licensee Sopiha Chen and explained the purpose of today’s visit. Currently there are 6 residents and 3 staff present. One of which is the administrator. LPA conducted a prelicensing inspection on this day in regards to CHOW. No citations issued. Report reviewed and a copy is provided to Sohpia Chen.
Other visitApril 8, 2026No deficiencies
Plain-language summary
On April 8, 2026, the state conducted an unannounced visit to the facility following notice of a change in ownership. The inspector met with the new licensee, reviewed the lease agreement and transition documents, and found no violations. The facility had 6 residents and 3 staff members present at the time of the visit.
View full inspector notes
On 04/08/2026, Licensing program Analyst (LPA) Jaime Vado conducted an unannounced case management visit in response to the email received in the Department on 04/06/2026 regarding facility closure/sale. LPA met with Administrator/Licensee Sopiha Chen and explained the purpose of today’s visit. Currently there are 6 residents and 3 staff present. One of which is the administrator. LPA discussed with Sophia, the new licensee, regarding the CHOW and the process with the previous licensee. LPA obtained a copy of the lease agreement that was signed in August 2025 between Sophia and the previous licensee. No citations issued at this time. Report is reviewed and a copy is provided to new licensee Sophia Chen.
Other visitFebruary 3, 2026No deficiencies
Plain-language summary
On February 3, 2026, a state inspector made an unannounced visit to observe the facility and check conditions in resident rooms, closets, and storage areas. The inspector found resident rooms properly furnished and families visiting, and confirmed that storage areas above the garage were not being used as living spaces. No violations were found.
View full inspector notes
On 02/03/2026, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - other visit in order to make observations within the facility. LPA met with caregiver Imelda Mendoza and explained the purpose of today's visit. During today's visit, LPA made facility observations. LPA observed resident rooms at random, linen closet and resident supply closet at the end of the hall, and observed the garage including the area above the garage. Resident rooms are in place with required furniture. Families are present visiting residents. The area above the garage is empty with no beds or living accommodations. There are other items that are being stored in this area but it is not being used as a living space and will continue being used for storage. The facility already has a designated staff room located in the main hallway area of the facility close to the resident rooms. Based on observations made this area is not being used for staff accommodations. No citations issued during today's visit. Report is reviewed with caregiver Imelda Mendoza.
InspectionJune 4, 2025No deficiencies
Plain-language summary
On June 4, 2025, a state licensing inspector conducted a routine annual inspection of this 8-bedroom facility licensed for seniors age 60 and over, currently serving 5 residents with 2 on hospice care. The inspector found the facility to be in compliance: emergency exits were clear, food and medication storage were secure, bathrooms were clean and safe, smoke and carbon monoxide detectors were functioning, and all resident files and medications were current and accurately documented. No violations were cited.
View full inspector notes
On 06/04/2025, Licensing program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection. LPA met with Administrator Eli Hart Ermitano and explained the purpose of today’s visit. Currently there are 5 residents and 2 staff present. One of which is the administrator. This is a single level facility with 8 bedrooms, 6 are for residents, and two are for staff. One staff room is located at the top of the garage. The facility is licensed for age 60 and over. All may be non-ambulatory. With a hospice waiver for 4 residents. At this time there is 2 resident under hospice care. 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. Dry goods/can goods are stored in a cabinet located in the garage. Knives are locked in a drawer adjacent to kitchen sink. Toxic chemicals/cleaning supplies are also observed to be locked in the garage of the facility and below the kitchen sink. Both the washer and dryer are observed as functional. There is are an additional freezer in the garage for resident food supplies. There is also a full refrigerator for staff in the garage. Medications are observed to be locked in a hallway closet. Each resident room observed contained the required furniture as outlined in regulations. All resident room also have a half bathroom with exception of bedroom 5, which has a full bathroom with a walk in shower. There is an additional full bathroom located near the front of the facility adjacent to the kitchen with a walk in shower and shower chairs. Non-skid flooring is present in both walk in showers. Resident bathrooms are observed as clean and in good worker order. 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 Facility has functioning smoke detectors within the facility as well as carbon monoxide detectors located in the main hallway. Fire extinguishers are observed with inspection dates of 05/06/2025. Water temperature is tested at 107F in full bathroom adjacent to the kitchen. LPA observed resident linen supplies stored in a hallway closet at the end of the main hallway. LPA inspected the medications and files of 5 residents in care at the facility. Based on review of all resident files, and medications all items are current and logged accurately. 4 staff files are reviewed and they are observed as current. Disaster/fire drill log is reviewed. Disaster drill observed as conducted on 03/27/2025 per training records reviewed. Facility administrator certificate is current expiring 10/20/2026 The following updated forms are requested to be submitted to CCLD by 06/12/2025 : • Copy of updated administrator certificate • Copy of facility's liability insurance • LIC308 Designation of responsible staff person • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule There are no citations issued on this day. LIC9102 TV is attached. Report is reviewed with administrator Eli Hart and a copy is provided.
Other visitJune 14, 2024Type B2 deficiencies
Inspector: Audrey Jeung
Plain-language summary
An inspector toured this six-bedroom facility and found that medications, chemicals, and cleaning supplies were stored safely and locked away, carbon monoxide and fire safety systems were in working order, and staff records and criminal clearances were properly reviewed. The facility was asked to provide updated proof of liability insurance by June 28, 2024. Some regulatory deficiencies were noted and are detailed in the full report.
View full inspector notes
LPA Audrey Jeung toured facility and grounds. This one level facility consists of 6 private client rooms--4 of which have private half or full bathrooms--2 staff rooms, bath/shower room, living/dining area, kitchen, and attached garage. Three residents currently receive hospice services. There is a detached storage shed in backyard. There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. There is no signal system in place, as facility employs awake overnight staff. Carbon monoxide detector is tested and operable. First-aid kit is maintained and complete. A staff room above 1-car garage has 3 beds and rear room on left side has a bunk bed and half bathroom. The backyard is fenced and accessible by 5 bedrooms with exit doors. Medications are stored in locked hall closet. Chemicals and cleaners are stored in garage and locked detached storage shed. An updated Disaster and Mass Casualty Plan is posted, and copy is given to LPA. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Eli Ermitano is a certified RCFE administrator (x10/24) that oversees facility operations. Client and staff records are reviewed. The following information is requested to be submitted to CCL by 6/28/24: Current proof of liability insurance for $1 million per incident and $3 million in annual aggregate. Deficiencies of the California Code of REgulations, Title 22 are cited on a following page. See also Technical Advisory Notes--3 pages.
Regulation
A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
Inspector finding
Based on record review, the licensee did not comply with the section cited above, as 2 residents use half bed rails, but there are no MD orders maintained. This poses a potential health, safety or personal rights risk to persons in care. Clients #4 and #5 are not on hospice and have half bed rails on their beds. There are no MD orders maintained. POC Due Date: 06/28/2024 Plan of Correction 1 2 3 4 MD orders for half bed rails for clients #4 and #5 will be sent to CCLD BY DUE DATE.
Regulation
Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.
Inspector finding
Based on staff record review, the licensee did not comply with the section cited above, as 2 staff have not received annual 8 hours of medication training, which poses a potential health, safety or personal rights risk to persons in care. Caregivers #1 and #2 received medication training over 12 months ago. They pass medications to residents. POC Due Date: 06/28/2024 Plan of Correction 1 2 3 4 Proof of required 8 hours of continuing medications training for staff #1 and #2 and all other conti…
InspectionJune 6, 2023Type B3 deficiencies
Inspector: Audrey Jeung
Plain-language summary
This was a follow-up inspection to check on corrections from a previous inspection in May 2023. The facility installed a shower grab bar in one room, added a low gate around a crawl space door, and repositioned a bed rail as required, but has not yet provided proof of current liability insurance to the state.
View full inspector notes
To complete annual inspection of 5/22/23, LPA Jeung reviewed staff training records and client records and interviewed staff and clients. In response to deficiency cited on 5/22/23, LPA observed that shower grab bar has been installed in bathroom in room #5. See PoC letter. As per Advisory Notes provided on 5/22/23, a low gate has been installed around the raised crawl space door in the rear of building and half bed rail has been repositioned to head of bed in room 3. Proof of current liability insurance is still pending and proof of required liability insurance to be submitted to CCLD. Deficiencies of California Code of Regulations, Title 22 are cited on a following page.
Regulation
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:
Inspector finding
Based on review of client records, the licensee did not comply with the section cited above, as client #4 was on hospice from 3/7/23 until 6/5/23 and hospice care plan was not maintained. This poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 06/20/2023 Plan of Correction 1 2 3 4 Hospice care plan for client #4 to be submitted to CCLD by DUE DATE, and will include use of half bed rails.
Regulation
Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
Inspector finding
Based on review of client records, the licensee did not comply with the section cited above, as client #1, who is diagnosed with dementia, has MD report dated 11/21 and appraisal dated 8/20. This poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 06/20/2023 Plan of Correction 1 2 3 4 MD report and appraisal for client 1 will be updated and copies will be sent to CCLD BY DUE DATE
Regulation
(h)(6) A record of centrally stored prescription medications for each resident shall be maintained and include names of the resident for whom prescribed, prescribing physician and pharmacist, drug name, strength and quantity, dates filled, started & expiration, prescription number and instructions:
Inspector finding
Based on review of clients' medications, the licensee did not comply with the section cited above, as medications are not logged on Centrally Stored Medications Records until medications are started or bottles are opened, instead of upon receipt. This poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 06/20/2023 Plan of Correction 1 2 3 4 All clients' medications shall be recorded on Centrally Stored Medications Records upon receipt, to document all cli…
InspectionMay 22, 2023Type B1 deficiency
Inspector: Audrey Jeung
Plain-language summary
This was a routine inspection of a seven-bedroom facility that found the home to be safe in terms of medication storage, hazardous materials handling, temperature control, lighting, and fire safety equipment—the facility has awake overnight staff and three residents use bed alarms for added safety. The inspector noted that some required administrative paperwork still needs to be completed and submitted, and at least one violation of California regulations was identified (details to follow in a separate citation). The inspection will continue at a later date to review client and staff training records.
View full inspector notes
LPA Audrey Jeung toured facility and grounds. There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. There is no signal system in place, as facility employs awake overnight staff. However, there are 3 clients who have bed alarms, which emit an audible signal when someone gets up from bed. Carbon monoxide detector is tested and operable. First-aid kit is maintained and complete. This facility is one level, with 7 client bedrooms, 2 full bathrooms, 4 half bathrooms, kitchen, living/dining room, staff room above garage and attached 1-car garage, where the washer and dryer are located. There are 3 beds in staff room above garage and room 4 is being used by female staff; there is a bunk bed and half bathroom in this room. The backyard is fenced and accessible by 5 bedrooms with exit doors. Medications are stored in locked hall closet. Chemicals and cleaners are stored in garage and locked detached storage shed. An updated Disaster and Mass Casualty Plan is posted, and copy is given to LPA. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Eli Ermitano is a certified RCFE administrator (x10/24) that oversees facility operations. Client records and Staff training records will be reviewed at a later date. The following forms are accessible at www.CDSS.ca.gov and are to be completed and returned to CCL by 6/5/23: • LIC 308 Designation of Administrative Responsibility, including Board resolution • LIC 309 Administrative Organization Proof of liability insurance for $1 million per incident and $3 million in annual aggregate 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 The following updated forms are provided to LPA during this visit: • LIC 500 Personnel Report • LIC 610 Emergency Disaster Plan • LIC 9282 Infection Control Plan Proof of current liability insurance Deficiency of the CA Code of REgulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page. Annual inspection to be continued and completed on a later date, due to time constraints. .
Regulation
MAINTENANCE AND OPERATION Grab bars shall be maintained for each toilet; bathtub and shower used by residents.
Inspector finding
Based on observation, the licensee did not comply with the section cited above, as full bathroom in room 5 does not have grab bar in shower stall, which poses a potential health, safety or personal rights risk to persons in care. This room was formerly used by staff, and bathroom was not used by residents. POC Due Date: 06/05/2023 Plan of Correction 1 2 3 4 Grab bars will be installed in bathroom in room 5. Proof of correction to be submitted to CCLD BY DUE DATE.
InspectionAugust 11, 2022Type A1 deficiency
Inspector: Audrey Jeung
Plain-language summary
During a routine inspection, the facility was found to have employed caregivers without required criminal background clearance — one current caregiver for 2 days, and a former caregiver for a period between September 2021 and June 2022. The facility was assessed civil penalties totaling $700 for these violations. The facility has 7 bedrooms with 5 private rooms currently occupied.
View full inspector notes
LPA Jeung met with staff and toured facility. There are 7 bedrooms, 5 of which are occupied as private rooms. There is a room above the garage with 3 beds for overnight caregivers. There are 2 caregivers on-site today. One does not have criminal record clearance. Based on information previously provided to CCLD, a former staff person worked at facility without criminal record clearance. This information was verified by administrator Ermitano. LPA reviewed staff file. Based on this information, deficiencies of the CA Code of Regulations, Title 22 are cited on a following page, and civil penalties are assessed: - Staff #1 has worked at facility for 2 days without criminal record clearance= $100/day x 2 days - Staff #2 worked at facility from 9/2021 - 6/2022 without criminal record clearance=$100/day x 5 days max.
Regulation
CRIMINAL RECORD CLEARANCE All individuals subject to a criminal record review pursuant to H & S Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility, obtain a CA clearance or a criminal record exemption as required by the Dept.: This requirement was not met , as staff #1
Inspector finding
is present and caring for clients & Staff #2 worked from 9/21 to 6/22 but do not have criminal record clearances nor exemptions. Licensee failed to ensure that staff who have client contact maintain criminal record clearance or exemption, which poses an immediate health and saftey risk to clients in care. Civil penalty of $200 is assessed for Staff #1 & $500 for staff #2 .
ComplaintJuly 7, 2021No deficiencies
Inspector: Gladys Kuizon
Plain-language summary
This was a routine annual inspection conducted on April 25, 2026, and no violations were found. The inspector confirmed that the facility has adequate supplies of medications and food, clear emergency exit routes, current resident emergency contact information, and COVID-19 infection control measures in place including hand sanitizers, face coverings for staff, and personal protective equipment available throughout the building. All residents and staff are fully vaccinated against COVID-19, and the facility is accepting visitors.
View full inspector notes
Licensing Program Analyst (LPA) Gladys Kuizon conducted an annual inspection today and met with Administrator Elaine Ermitano. LPA entered the facility through the facility's central entry point. 1 resident was observed watching TV in the living room. LPA was screened by staff upon entrance. At 12:51 PM, a tour of the facility was conducted. The facility's screening procedures were reviewed. COVID-19 postings including hand-washing and infection control guides were observed throughout the facility including on the main entrance, hallways, and bathrooms. Staff were observed wearing face coverings. The facility has a supply of personal protective equipment (PPE) including face shields, isolation gowns, gloves, and face masks. Hand sanitizers, soap, and single use hand towels were observed available. The facility has at least 30 days' supply of residents' medications. At least 2 days' supply of perishable food and at least 1 week's supply on non-perishable food supply was observed in the premises. Per Administrator, all residents and staff are fully vaccinated against COVID-19. The facility is currently accepting visitors inside the facility. A designated visitation area is available. Exit routes were observed clear and unobstructed. No open bodies of water were observed. Resident roster with current emergency contact information is available. The facility's COVID-19 mitigation plan was reviewed and discussed with Administrator. No deficiencies were cited. Exit interview conducted with Administrator and a copy of this report was provided during visit.
Federal summary
CMS Care CompareNot a CMS-certified facility
California RCFEs (residential care facilities for the elderly) are licensed by the state, not by CMS. CMS data only applies to skilled nursing facilities or to CCRCs that operate a licensed SNF wing.
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