Pre-licensing visit·November 18, 2021

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 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.