Resident rights
Cited in 2 reports, with 2 deficiencies in total.
CADENCE MILLBRAE
1201 BROADWAY, Millbrae CA 94030
165 bedsLatest official report Jul 23, 2026Licensed
Additional info
- Telephone
- (650) 742-9150
- Licensee
- 1201 BROADWAY-OPERATOR LLC;CADENCE SL MILLBRAE LLC
- Administrator
- HOLLY SUITER
- Contact
- HOLLY SUITER
- License first date
- Aug 1, 2018
- License effective date
- Aug 1, 2018
- District office
- SAN BRUNO RO · (650) 266-8800
- Regional office
- 14
- Clients served
- 983 - RCFE / DEMENTIA
Summary
The available records show 9 Type A and 4 Type B deficiencies for this facility.
- Most recent inspection
- Jul 23, 2026
- Most recent deficiency
- Nov 25, 2025
2 later reports, from Jul 8, 2026 through Jul 23, 2026, recorded no deficiencies, though the records do not say whether they were follow-ups.
What Type A and Type B mean
- Type A
- Violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
- Type B
- Violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care.
Both classifications are published by California CDSS and are shown as published. SeniorLivingFacts does not rename them or add a severity level of its own.
At a glance
Counts cover the five-year public record. Typical figures are the median for the 28 San Mateo County facilities licensed for 50 or more beds, except where too few exist to state one — those come from facilities with 7 or more beds.
In the available public five-year record, CCLD published 26 reports for this facility: 14 inspections, 11 complaint investigations, and 1 licensing or administrative record.
Those records contain 9 Type A and 4 Type B deficiencies.
0 deficiencies have explicit official correction or clearance evidence in the loaded records.
- Official inspections
- 14
- Recorded deficiencies
- 13
- Type A deficiencies
- 9
- Type B deficiencies
- 4
- Substantiated complaints
- 3
- Repeated topics
- 1
More than the typical 6
3 in the last 12 months
Well above the typical 4
1 in the last 12 months
Well above the typical 1
1 in the last 12 months
More than the typical 1
0 in the last 12 months
Most this size have none
0 in the last 12 months
Last 36 months
Repeated topics
Topics cited in more than one report during the last 36 months. A repeat may show a pattern worth asking about. Each date opens its report below.
Official report history
All preserved reports from the most recent to the oldest, sortable by report type.
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Inspection
Resident rightsType A
- Official classification
- Type A
- Official code
- 87468.1(a)(2)
- Regulation authority
- CCR
What the official deficiency says
87468.1(a)(2) Personal Rights of Residents in All Facilities - To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This regulation has not been met as evidenced by: 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.
Official plan of correction
The facility, licensee/administrator, shall conduct an in-service training with staff regarding Resident Rights, including types of abuse, handling residents with behaviors, etc. Evidence of such training to be recieved by due date.
Deadline recorded: Nov 26, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Nov 26, 2025
Correction not verified in available records
Inspection
No deficiencies recorded in this report
Complaint
Allegations0 substantiated · 1 unsubstantiated · 1 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 2 unsubstantiated · 1 unfounded
No deficiencies recorded in this reportInspection
No deficiencies recorded in this report
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Medication handling and storageType A
- Official classification
- Type A
- Official code
- 87465(c)(2)
- Regulation authority
- CCR
What the official deficiency says
87465(c)(2) Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This regulation has not been met as evidenced by: 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.
Official plan of correction
The facility shall develop a plan of correction addressing how this regulation will be met at all times. Plan of correction to be received by 11/09/2024.
Deadline recorded: Nov 9, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Nov 9, 2024
Correction not verified in available records
Inspection
Records and plan of operationType B
- Official classification
- Type B
- Official code
- 87506(e)
- Regulation authority
- CCR
What the official deficiency says
87506(e) Resident Records - Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This regulation has not been met as evidenced by: 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.
Official plan of correction
The facility shall develop a plan of correction addressing how this regulation will be met at all times. Plan of correction to be received by 10/04/2024.
Deadline recorded: Oct 4, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Oct 4, 2024
Correction not verified in available records
Inspection
No deficiencies recorded in this report
Licensing recordNot an inspection of the operating facility
No deficiencies recorded in this report
Complaint
Allegations0 substantiated · 1 unsubstantiated · 1 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations4 substantiated · 0 unsubstantiated · 0 unfounded · 4 cited · investigated over 2 visits
Admission, assessment, and evictionType A
- Official classification
- Type A
- Official code
- 87463(a)(4)
- Regulation authority
- CCR
What the official deficiency says
87463 Reappraisals - (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions. This regulation has not been met as evidenced by: 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.
Official plan of correction
The licensee shall create a plan of correction to ensure that this regulation is met at all times.
Deadline recorded: Mar 2, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 2, 2024
Correction not verified in available records
Resident rightsType A
- Official classification
- Type A
- Official code
- 87468.2(a)(4)
- Regulation authority
- CCR
What the official deficiency says
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities - (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This regulation has not been met as evidenced by: 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.
Official plan of correction
The licensee shall create a plan of correction to ensure that this regulation is met at all times.
Deadline recorded: Mar 2, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 2, 2024
Correction not verified in available records
Complaint
Part of the complaint whose outcome is recorded on Mar 1, 2024 · Control 14-AS-20230804102303
Basic services and supervisionType A
- Official classification
- Type A
- Official code
- 87464
- Regulation authority
- CCR
What the official deficiency says
87464 BASIC SERVICES - Basic services shall ... include care and supervision as defined in 87101(c)(3) and Health and Safety Code 1569.2(c), meaning the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with ADLs without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement was not met as evidenced by: Based on investigation the licensee failed to ensure adequate supervision of a client who was a fall risk by leaving resident with fall risks alone, which poses immediate health, safety, or personal rights risk to clients in care.
Official plan of correction
Plan/proof of correction to be submitted to CCLD BY DUE DATE
Deadline recorded: Feb 23, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Feb 23, 2024
Correction not verified in available records
Basic services and supervisionType A
- Official classification
- Type A
- Official code
- 87466
- Regulation authority
- CCR
What the official deficiency says
87466 OBSERVATION OF RESIDENT - The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes...are observed...such brought to the attention of the resident's physician and the resident's responsible person. This requirement was not met as evidenced by: Based on the investigation licensee failed to monitor changes in resident and failed to seek medical attention to address medical needs.
Official plan of correction
Plan/proof of correction to be sent to CCLD BY DUE DATE
Deadline recorded: Feb 23, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Feb 23, 2024
Correction not verified in available records
Inspection
Licensing and administrationType B
- Official classification
- Type B
- Official code
- 87109(d)
- Regulation authority
- CCR
What the official deficiency says
TRANSFERABILITY OF LICENSE In the case of change of ownership or licensee a new application for license shall be submitted by the prospective new licensee. This requirement was not met, as Cogir Management USA Inc. acquired Cadence, and application for new licensure has not yet been submitted. This poses a potential health, safety or personal rights risk to clients in care.
Official plan of correction
Plan of correction to be submitted to CCLD BY DUE DATE
Deadline recorded: Aug 10, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Aug 10, 2023
Correction not verified in available records
Inspection
No deficiencies recorded in this report
Complaint
Allegations2 substantiated · 0 unsubstantiated · 0 unfounded · 2 cited
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(b)(2)
- Regulation authority
- CCR
What the official deficiency says
MAINTENANCE AND OPERATION A comfortable temperature for residents shall be maintained at all times. The facility shall cool rooms to a comfortable range, between 78 degrees F and 85 degrees F, or in areas of extreme heat to 30 degrees F less than the outside temperature. This requirement was not met, as extreme heat existed in September 2022, when temperature was up to 97 degrees, and rooms on the west side of building were not comfortably cool. Licensee failed to ensure that residents' apartments were maintained at comfortable temperature, which posed a potential health, safety or personal rights risk to clients in care.
Official plan of correction
Plan of correction to be submitted to CCLD BY DUE DATE
Deadline recorded: Jun 22, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jun 22, 2023
Correction not verified in available records
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87507(f)
- Regulation authority
- CCR
What the official deficiency says
ADMISSION AGREEMENTS The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met, as licensee failed to ensure that residents' apartments were air conditioned--as stated in residency agreements--which posed a potential health, safety or personal rights risk to clients in care.
Official plan of correction
Residency Agreements were revised, and no longer state that apartments are air conditioned. Copy of updated admission agreement is provided to LPA today. Deficiency corrected and cleared.
Deadline recorded: Jun 8, 2023. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Jun 8, 2023
Correction not verified in available records
Inspection
No deficiencies recorded in this report
Complaint
Allegations0 substantiated · 0 unsubstantiated · 2 unfounded
No deficiencies recorded in this reportInspection
No deficiencies recorded in this report
Complaint
Allegations0 substantiated · 3 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportInspection
Incident reportingType A
- Official classification
- Type A
- Official code
- 87211(a)(2)
- Regulation authority
- CCR
What the official deficiency says
REPORTING REQUIREMENTS Licensee shall furnish to CCLD reports, including written report within 7 days of the occurrence of an epidemic outbreak, which threatens the welfare, safety or health of residents, personnel or visitors. Report shall be made within 24 hours either by telephone or fax to CCLD & to the local health officer when appropriate. Report shall include the resident's name, age, sex, date of admission... This requirement was not met, as at least 14 staff & 7 clients with Covid were not reported to CCLD. Licensee failed to report COVID infections to CCLD and County Public Health Dept., which poses an immediate health and safety risk to clients in care.
Official plan of correction
Plan of correction to be submitted to CCLD BY DUE DATE, which shall include proof that appropriate reports were made to San Mateo Co. Public Health
Deadline recorded: May 31, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline May 31, 2022
Correction not verified in available records
Health conditions and treatmentsType A
- Official classification
- Type A
- Official code
- 87470(b)(2)
- Regulation authority
- CCR
What the official deficiency says
INFECTION CONTROL REQUIREMENTS All staff & volunteers providing direct care to a resident who has a communicable disease shall wear appropriate PPE to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection. This requirement was not met, as staff M.L. was observed through open door to be assisting COVID client wearing surgical mask--no gloves, no isolation gown, no N95. Licensee failed to ensure that staff with direct contact to clients with COVID are appropriately attired in full PPE, which poses an immediate health, safety, or personal rights risk to clients in care.
Official plan of correction
Plan of correction to be submitted to CCLD BY DUE DATE, which shall include proof that staff received relevant training on donning and doffing of PPE.
Deadline recorded: May 31, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline May 31, 2022
Correction not verified in available records
Resident rightsType A
- Official classification
- Type A
- Official code
- 87468.1(a)(2)
- Regulation authority
- CCR
What the official deficiency says
PERSONAL RIGHTS IN ALL FACILITIES Residents in all RCFEs shall have the personal rights to be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met, as procedures for mitigation of COVID are not being followed: rooms of clients with COVID infection are not designated as restricted entry, nor are there isolation carts outside of rooms for care staff to don and doff full PPE when entering and exiting rooms. Staff and residents are not being screened daily for COVID symptoms and fever. Licensee failed to ensure that procedures to mitigate the spread of COVID infections are being followed according to facility's COVID plan, which poses an immediate health, safety or personal rights risk.
Official plan of correction
Plan of correction to be submitted to CCLD BY DUE DATE
Deadline recorded: May 31, 2022. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline May 31, 2022
Correction not verified in available records
Inspection
No deficiencies recorded in this report
Inspection
No deficiencies recorded in this report
Source and limits
California Department of Social Services, Community Care Licensing Division. Public facility history is described by the source as a five-year window. Older records and previous-licensee history may require a regional-office request. Type 741 RCFE-CCRCs, nursing homes, and other care settings are excluded from this page.
Read the data methodology