Millbrae Assisted Living Home

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.

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... 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 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.

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.

Applicant Millbrae Assisted Living Home LLC, represented by COO Jason Mullen, has applied for RCFE licensure for 48 bedridden elderly persons. Fire clearance has been approved. Facility is currently operated as Millbrae Assisted Living Center LLC #415600904. 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. Facility sketch accurately reflects floor plan. Medications are secured in medication room and toxins are secured in locked maintenance room on ground floor. Food preparation and service items are present, as well as perishable and non-perishable food. Supplies of 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 after adjustment. There is an emergency call system installed in each bedroom and bathroom, that transmits audible and visual signal to reception desk on ground floor. The following items are observed and must be addressed prior to licensure: 1. Additional COVID signs must be posted--cough/sneeze etiquette, reminders to practice social distancing and wear masks. 2. There is no COVID visitation policy posted at front door. 3. Emergency Disaster Plan (LIC610E) is incomplete. See LIC9102TV. 4. Additional carbon monoxide detector to be installed on second floor. See LIC9102TV. 5. Personal Rights posted are incomplete. See LIC9102TV. 6. Activity calendar must be posted. See LIC9102TV 7. Nondiscrimination notice should be posted. See LIC9102TV. 8. Bedridden plan of operation has not yet been submitted to CCLD. See LIC9102TV. 9. Additional evacuation chair must be present. See LIC9102TV. Continued on page TWO 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 Continuation: 10. Liquid soap should replace bar soap in shared bathrooms. See LIC9102TV. Items above will be addressed and shall be verified by LPA prior to licensure. Facility phone number is 650/689-5776. Component III orientation is completed and discussed with Ms. Lucero and Mr. Mullen.

Facility Type: RCFE Application Type: CHOW Capacity: 48 Census: 48 COMP II Participants: Lucero, Mary Ann, Po, Ginger Interview Method: Telephone interview On 10/01/2021, Ginger Po and Mary Ann Lucero in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readines s