Millbrae Care Center, Millbrae, CA: Nursing home

Overall2★★☆☆☆

Inspections2★★☆☆☆

Staffing3★★★☆☆

Quality4★★★★☆

Federal fines$7,0451 fine

Inspection citations

13’21

25’24

2’25

20’26

Year

60 shown

Date	Severity	What inspectors found	Visit
Aug 13, 2026	D · potential	Protect each resident from the wrongful use of the resident's belongings or money.	Complaint
Aug 13, 2026	D · potential	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	Complaint
Aug 13, 2026	D · potential	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.	Complaint
Jun 25, 2026	E · potential	Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.	Complaint
Jun 25, 2026	E · potential	Ensure that the resident and his/her doctor meet face-to-face at all required visits.	Complaint
May 8, 2026	D · potential	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	Complaint
May 8, 2026	D · potential	Respond appropriately to all alleged violations.	Complaint
May 8, 2026	D · potential	Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.	Routine
May 8, 2026	D · potential	Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.	Routine
May 8, 2026	D · potential	Assess the resident when there is a significant change in condition	Routine
May 8, 2026	E · potential	Assure that each resident’s assessment is updated at least once every 3 months.	Routine
May 8, 2026	F · potential	Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.	Routine
May 8, 2026	E · potential	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	Routine
May 8, 2026	D · potential	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	Routine
May 8, 2026	D · potential	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	Routine
May 8, 2026	D · potential	Provide safe and appropriate respiratory care for a resident when needed.	Routine
May 8, 2026	E · potential	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.	Routine
May 8, 2026	D · potential	Provide and implement an infection prevention and control program.	Routine
Jan 28, 2026	D · potential	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	Complaint
Jan 28, 2026	D · potential	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	Complaint
Jun 4, 2025	E · potential	Provide medically-related social services to help each resident achieve the highest possible quality of life.	Complaint
May 19, 2025	D · potential	Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.	Complaint
Oct 17, 2024	D · potential	Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.	Routine
Oct 17, 2024	D · potential	Ensure each resident receives an accurate assessment.	Routine
Oct 17, 2024	D · potential	Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.	Routine
Oct 17, 2024	D · potential	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	Routine
Oct 17, 2024	D · potential	Provide timely, quality laboratory services/tests to meet the needs of residents.	Routine
Oct 17, 2024	E · potential	Provide and implement an infection prevention and control program.	Routine
Oct 17, 2024	B · minimal	Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.	Routine
Oct 17, 2024	E · potential	Have policies on smoking.	Routine
Aug 5, 2024	E · potential	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.	Complaint
Jun 7, 2024	D · potential	Provide medically-related social services to help each resident achieve the highest possible quality of life.	Complaint
Apr 11, 2024	D · potential	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	Complaint
Apr 11, 2024	D · potential	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	Complaint
Jan 11, 2024	D · potential	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	Complaint
Jan 11, 2024	D · potential	Reasonably accommodate the needs and preferences of each resident.	Complaint
Jan 11, 2024	D · potential	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	Complaint
Jan 11, 2024	D · potential	Assess the resident when there is a significant change in condition	Complaint
Jan 11, 2024	F · potential	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.	Complaint
Jan 11, 2024	G · harm	Provide enough food/fluids to maintain a resident's health.	Complaint
Jan 11, 2024	D · potential	Provide or get specialized rehabilitative services as required for a resident.	Complaint
Jan 11, 2024	F · potential	Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.	Complaint
Jan 11, 2024	D · potential	Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.	Complaint
Jan 11, 2024	F · potential	Make sure that a working call system is available in each resident's bathroom and bathing area.	Complaint
Jan 11, 2024	E · potential	Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	Complaint
Jan 3, 2024	E · potential	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	Complaint
Jan 3, 2024	E · potential	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	Complaint
Dec 3, 2021	E · potential	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	Routine
Dec 3, 2021	E · potential	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	Routine
Dec 3, 2021	G · harm	Provide enough food/fluids to maintain a resident's health.	Routine
Dec 3, 2021	D · potential	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	Routine
Dec 3, 2021	E · potential	Ensure medication error rates are not 5 percent or greater.	Routine
Dec 3, 2021	D · potential	Ensure that residents are free from significant medication errors.	Routine
Dec 3, 2021	E · potential	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.	Routine
Dec 3, 2021	E · potential	Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.	Routine
Dec 3, 2021	E · potential	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.	Routine
Dec 3, 2021	D · potential	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	Routine
Dec 3, 2021	D · potential	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	Routine
Dec 3, 2021	E · potential	Provide and implement an infection prevention and control program.	Routine
Dec 3, 2021	D · potential	Keep all essential equipment working safely.	Routine

Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.

Questions to ask on a visit

Millbrae Care Center
33 Mateo Avenue, Millbrae, CA 94030 · (650) 689-5784

Visit date: ____________ Spoke with: ______________________

How many nurses and aides work each shift, including nights and weekends?
How do you handle the most recent citations on your record?
Do you accept Medi-Cal if private funds run out?
Who will be the main contact for the family?
How do you prevent falls, pressure sores and infections?

Record on file

Certification: Medicare and Medi-Cal certified skilled nursing facility
Medicare number (CCN): 056122
Certified beds: 140
Legal owner: Millbrae Care Center LLC

Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.

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Millbrae Care Center

Inspection citations

Questions to ask on a visit

Record on file

Nursing homes near Millbrae

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