Facility WatchInspection records for every certified US nursing home
Millbrae Care Center
33 Mateo Avenue Millbrae, CA 94030 (650) 689-5784
CCN
056122
Certified beds
140
Ownership
For profit - Limited Liability company
Nurse staffing
3.71
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.47 hours per resident per day
Nursing staff turnover: 33% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected January 28, 2026
2 citations · from a complaint investigation · Health
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected March 5, 2026
D
F0657No actual harm with potential for more than minimal harm · Isolated
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected March 5, 2026
Inspected June 4, 2025
1 citation · from a complaint investigation · Health
E
F0745No actual harm with potential for more than minimal harm · Pattern
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Deficient, Provider has date of correction · corrected July 2, 2025
Inspected May 19, 2025
1 citation · from a complaint investigation · Health
D
F0557No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Deficient, Provider has date of correction · corrected July 2, 2025
Inspected October 17, 2024
8 citations · Health
B
F0911No actual harm with potential for minimal harm · Pattern
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Deficient, Provider has date of correction · corrected November 17, 2024
D
F0640No actual harm with potential for more than minimal harm · Isolated
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Deficient, Provider has date of correction · corrected November 17, 2024
D
F0641No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives an accurate assessment.
Deficient, Provider has date of correction · corrected November 17, 2024
D
F0644No actual harm with potential for more than minimal harm · Isolated
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Deficient, Provider has date of correction · corrected November 17, 2024
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected November 17, 2024
D
F0770No actual harm with potential for more than minimal harm · Isolated
Provide timely, quality laboratory services/tests to meet the needs of residents.
Deficient, Provider has date of correction · corrected November 17, 2024
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected November 17, 2024
E
F0926No actual harm with potential for more than minimal harm · Pattern
Have policies on smoking.
Deficient, Provider has date of correction · corrected November 17, 2024
Inspected August 5, 2024
1 citation · from a complaint investigation · Health
E
F0726No actual harm with potential for more than minimal harm · Pattern
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Deficient, Provider has date of correction · corrected September 5, 2024
Inspected June 7, 2024
1 citation · from a complaint investigation · Health
D
F0745No actual harm with potential for more than minimal harm · Isolated
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Deficient, Provider has date of correction · corrected July 5, 2024
Inspected April 11, 2024
2 citations · from a complaint investigation · Health
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected May 10, 2024
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected May 10, 2024
Inspected January 11, 2024
11 citations · from a complaint investigation · Health
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected March 21, 2024
D
F0558No actual harm with potential for more than minimal harm · Isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected March 21, 2024
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected March 21, 2024
D
F0637No actual harm with potential for more than minimal harm · Isolated
Assess the resident when there is a significant change in condition
Deficient, Provider has date of correction · corrected March 21, 2024
D
F0825No actual harm with potential for more than minimal harm · Isolated
Provide or get specialized rehabilitative services as required for a resident.
Deficient, Provider has date of correction · corrected March 21, 2024
D
F0911No actual harm with potential for more than minimal harm · Isolated
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Deficient, Provider has date of correction · corrected March 21, 2024
E
F0921No actual harm with potential for more than minimal harm · Pattern
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Deficient, Provider has date of correction · corrected March 21, 2024
F
F0688No actual harm with potential for more than minimal harm · Widespread
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Deficient, Provider has date of correction · corrected March 21, 2024
F
F0867No actual harm with potential for more than minimal harm · Widespread
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Deficient, Provider has date of correction · corrected March 21, 2024
F
F0919No actual harm with potential for more than minimal harm · Widespread
Make sure that a working call system is available in each resident's bathroom and bathing area.
Deficient, Provider has date of correction · corrected March 21, 2024
G
F0692Actual harm · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected March 21, 2024
Inspected January 3, 2024
2 citations · from a complaint investigation · Health
E
F0609No actual harm with potential for more than minimal harm · Pattern
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected March 18, 2024
E
F0689No actual harm with potential for more than minimal harm · Pattern
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected March 18, 2024
Inspected August 24, 2023
2 citations · from a complaint investigation · Health
D
F0607No actual harm with potential for more than minimal harm · Isolated
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Deficient, Provider has date of correction · corrected September 28, 2023
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected September 28, 2023
Inspected August 2, 2023
1 citation · from a complaint investigation · Health
D
F0607No actual harm with potential for more than minimal harm · Isolated
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Deficient, Provider has date of correction · corrected August 18, 2023
Inspected July 19, 2023
1 citation · from a complaint investigation · Health
D
F0607No actual harm with potential for more than minimal harm · Isolated
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Deficient, Provider has date of correction · corrected July 28, 2023
Inspected June 28, 2023
1 citation · from a complaint investigation · Health
D
F0583No actual harm with potential for more than minimal harm · Isolated
Keep residents' personal and medical records private and confidential.
Deficient, Provider has date of correction · corrected August 2, 2023
Inspected December 3, 2021
13 citations · Health
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected March 10, 2022
D
F0760No actual harm with potential for more than minimal harm · Isolated
Ensure that residents are free from significant medication errors.
Deficient, Provider has date of correction · corrected March 10, 2022
D
F0804No actual harm with potential for more than minimal harm · Isolated
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Deficient, Provider has date of correction · corrected January 28, 2022
D
F0812No actual harm with potential for more than minimal harm · Isolated
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected January 28, 2022
D
F0908No actual harm with potential for more than minimal harm · Isolated
Keep all essential equipment working safely.
Deficient, Provider has date of correction · corrected January 28, 2022
E
F0684No actual harm with potential for more than minimal harm · Pattern
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected January 28, 2022
E
F0689No actual harm with potential for more than minimal harm · Pattern
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected January 28, 2022
E
F0759No actual harm with potential for more than minimal harm · Pattern
Ensure medication error rates are not 5 percent or greater.
Deficient, Provider has date of correction · corrected March 10, 2022
E
F0761No actual harm with potential for more than minimal harm · Pattern
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Deficient, Provider has date of correction · corrected March 10, 2022
E
F0802No actual harm with potential for more than minimal harm · Pattern
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Deficient, Provider has date of correction · corrected March 10, 2022
E
F0803No actual harm with potential for more than minimal harm · Pattern
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Deficient, Provider has date of correction · corrected January 28, 2022
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected March 10, 2022
G
F0692Actual harm · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected January 28, 2022
Inspected July 25, 2019
15 citations · Health
D
F0558No actual harm with potential for more than minimal harm · Isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected October 3, 2019
D
F0636No actual harm with potential for more than minimal harm · Isolated
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Deficient, Provider has date of correction · corrected October 3, 2019
D
F0640No actual harm with potential for more than minimal harm · Isolated
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Deficient, Provider has date of correction · corrected October 3, 2019
D
F0641No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives an accurate assessment.
Deficient, Provider has date of correction · corrected October 3, 2019
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected October 3, 2019
D
F0688No actual harm with potential for more than minimal harm · Isolated
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Deficient, Provider has date of correction · corrected October 3, 2019
D
F0700No actual harm with potential for more than minimal harm · Isolated
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Deficient, Provider has date of correction · corrected October 3, 2019
D
F0732No actual harm with potential for more than minimal harm · Isolated
Post nurse staffing information every day.
Deficient, Provider has date of correction · corrected October 3, 2019
D
F0745No actual harm with potential for more than minimal harm · Isolated
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Deficient, Provider has date of correction · corrected October 3, 2019
D
F0840No actual harm with potential for more than minimal harm · Isolated
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Deficient, Provider has date of correction · corrected October 3, 2019
D
F0921No actual harm with potential for more than minimal harm · Isolated
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Deficient, Provider has date of correction · corrected October 3, 2019
E
F0755No actual harm with potential for more than minimal harm · Pattern
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected October 3, 2019
E
F0812No actual harm with potential for more than minimal harm · Pattern
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected October 3, 2019
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected October 3, 2019
F
F0836No actual harm with potential for more than minimal harm · Widespread
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Deficient, Provider has date of correction · corrected October 3, 2019
Penalties
Date
Type
Amount
January 3, 2024
Fine
$7,045
Ownership transfers
Effective
Seller
Buyer
07/01/2019
Millbrae Skilled Care LLC
Millbrae Care Center LLC
From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.