C71

MILLBRAE CARE CENTER

Grade C 71/100 composite score

For profit - Limited Liability company

CMS Star Ratings

Overall
2/5
Health Insp.
2/5
Quality
2/5
Staffing
3/5
RN Staffing
Not rated

Certified Beds

140

Ownership

For profit - Limited Liability company

Total Fines

$16,795

Last Survey

N/A

33 MATEO AVENUE, MILLBRAE, CA 94030
6506895784

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.57h
LPN
1.06h
CNA
2.08h
Total
3.72h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

CHOY, ESTRELLA

Individual5% OR GREATER DIRECT OWNERSHIP INTERESTSince Jul 2019

10%

MAYER, RONALD

Individual5% OR GREATER DIRECT OWNERSHIP INTERESTSince Jul 2019

65%

PERETZ, ASHER

Individual5% OR GREATER DIRECT OWNERSHIP INTERESTSince Jul 2019

10%

RODRIGUEZ, ELSA

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jul 2019

Penalties & Fines (2)

$16,795total fines
DateTypeDescriptionAmount
Jan 3, 2024Fine$7,045
Feb 14, 2023Fine$9,750

Health Inspection Deficiencies (71)

June 4, 2025Health1 deficiency
0745EMinimal harm, Pattern

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Quality of Life and Care Deficiencies

Corrected Jul 2, 2025
May 19, 2025Health1 deficiency
0557DMinimal harm, Isolated

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Resident Rights Deficiencies

Corrected Jul 2, 2025
October 17, 2024Health8 deficiencies
0640DMinimal harm, Isolated

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 17, 2024
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 17, 2024
0644DMinimal harm, Isolated

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 17, 2024
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Nov 17, 2024
0770DMinimal harm, Isolated

Provide timely, quality laboratory services/tests to meet the needs of residents.

Administration Deficiencies

Corrected Nov 17, 2024
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Nov 17, 2024
0911BNo 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.

Environmental Deficiencies

Corrected Nov 17, 2024
0926EMinimal harm, Pattern

Have policies on smoking.

Environmental Deficiencies

Corrected Nov 17, 2024
August 5, 2024Health1 deficiency
0726EMinimal 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.

Nursing and Physician Services Deficiencies

Corrected Sep 5, 2024
June 7, 2024Health1 deficiency
0745DMinimal harm, Isolated

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Quality of Life and Care Deficiencies

Corrected Jul 5, 2024
April 11, 2024Health2 deficiencies
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected May 10, 2024
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected May 10, 2024
January 11, 2024Health11 deficiencies1 severe
0550DMinimal harm, Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Mar 21, 2024
0558DMinimal harm, Isolated

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Mar 21, 2024
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Mar 21, 2024
0637DMinimal harm, Isolated

Assess the resident when there is a significant change in condition

Resident Assessment and Care Planning Deficiencies

Corrected Mar 21, 2024
0688FMinimal 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.

Quality of Life and Care Deficiencies

Corrected Mar 21, 2024
0692GActual harm, Isolated

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Mar 21, 2024
0825DMinimal harm, Isolated

Provide or get specialized rehabilitative services as required for a resident.

Quality of Life and Care Deficiencies

Corrected Mar 21, 2024
0867FMinimal harm, Widespread

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Administration Deficiencies

Corrected Mar 21, 2024
0911DMinimal 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.

Environmental Deficiencies

Corrected Mar 21, 2024
0919FMinimal harm, Widespread

Make sure that a working call system is available in each resident's bathroom and bathing area.

Environmental Deficiencies

Corrected Mar 21, 2024
0921EMinimal harm, Pattern

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies

Corrected Mar 21, 2024
January 3, 2024Health2 deficiencies
0609EMinimal harm, Pattern

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Mar 18, 2024
0689EMinimal harm, Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Mar 18, 2024
August 24, 2023Health2 deficiencies
0607DMinimal harm, Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Sep 28, 2023
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Sep 28, 2023
August 2, 2023Health1 deficiency
0607DMinimal harm, Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Aug 18, 2023
July 19, 2023Health1 deficiency
0607DMinimal harm, Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jul 28, 2023
June 28, 2023Health1 deficiency
0583DMinimal harm, Isolated

Keep residents' personal and medical records private and confidential.

Resident Rights Deficiencies

Corrected Aug 2, 2023
April 13, 2023Health2 deficiencies
0607DMinimal harm, Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jul 28, 2023
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jul 28, 2023
March 30, 2023Health1 deficiency
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Apr 8, 2023
February 16, 2023Health1 deficiency
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Apr 3, 2023
February 15, 2023Health2 deficiencies
0585DMinimal harm, Isolated

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Resident Rights Deficiencies

Corrected Mar 31, 2023
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Mar 27, 2023
February 14, 2023Health5 deficiencies
0554DMinimal harm, Isolated

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Corrected Mar 29, 2023
0557DMinimal harm, Isolated

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Resident Rights Deficiencies

Corrected Mar 29, 2023
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Mar 29, 2023
0921DMinimal harm, Isolated

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies

Corrected Mar 29, 2023
0940EMinimal harm, Pattern

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Administration Deficiencies

Corrected Mar 29, 2023
December 3, 2021Health13 deficiencies1 severe
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Mar 10, 2022
0908DMinimal harm, Isolated

Keep all essential equipment working safely.

Environmental Deficiencies

Corrected Jan 28, 2022
0684EMinimal harm, Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Jan 28, 2022
0689EMinimal harm, Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Jan 28, 2022
0692GActual harm, Isolated

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Jan 28, 2022
0755DMinimal harm, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Mar 10, 2022
0759EMinimal harm, Pattern

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Mar 10, 2022
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Mar 10, 2022
0761EMinimal 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.

Pharmacy Service Deficiencies

Corrected Mar 10, 2022
0802EMinimal harm, Pattern

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Nutrition and Dietary Deficiencies

Corrected Mar 10, 2022
0803EMinimal 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.

Nutrition and Dietary Deficiencies

Corrected Jan 28, 2022
0804DMinimal harm, Isolated

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Corrected Jan 28, 2022
0812DMinimal harm, Isolated

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Jan 28, 2022
July 25, 2019Health15 deficiencies
0558DMinimal harm, Isolated

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Oct 3, 2019
0636DMinimal harm, Isolated

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 3, 2019
0640DMinimal harm, Isolated

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 3, 2019
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 3, 2019
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 3, 2019
0688DMinimal 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.

Quality of Life and Care Deficiencies

Corrected Oct 3, 2019
0700DMinimal 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.

Quality of Life and Care Deficiencies

Corrected Oct 3, 2019
0732DMinimal harm, Isolated

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies

Corrected Oct 3, 2019
0745DMinimal harm, Isolated

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Quality of Life and Care Deficiencies

Corrected Oct 3, 2019
0755EMinimal harm, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Oct 3, 2019
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Oct 3, 2019
0836FMinimal 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.

Administration Deficiencies

Corrected Oct 3, 2019
0840DMinimal 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.

Administration Deficiencies

Corrected Oct 3, 2019
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Oct 3, 2019
0921DMinimal harm, Isolated

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies

Corrected Oct 3, 2019

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Frequently Asked Questions

What is the CareGrader rating for MILLBRAE CARE CENTER?

MILLBRAE CARE CENTER in MILLBRAE, California has a CareGrader grade of C (Average), with a composite score of 70.5 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for MILLBRAE CARE CENTER?

MILLBRAE CARE CENTER has an overall CMS star rating of 2 out of 5, a health inspection rating of 2/5, and a staffing rating of 3/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does MILLBRAE CARE CENTER have?

MILLBRAE CARE CENTER has 71 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has MILLBRAE CARE CENTER been fined?

Yes. MILLBRAE CARE CENTER has $16,795 in total fines from CMS enforcement actions across 2 penalties.

How many beds does MILLBRAE CARE CENTER have?

MILLBRAE CARE CENTER has 140 certified beds with approximately 127 current residents (91% occupancy). The facility is located at 33 MATEO AVENUE, MILLBRAE, California 94030. It is a for profit - limited liability company facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.