★★★★★Overall Medicare rating
★★★★★Health inspections
★★★★★Staffing
★★★★★Quality measures
Medicare rates every nursing home from 1 to 5 stars. 5 is much above average, 1 is much below.
Findings, latest cycle20
Findings with harm or immediate jeopardy, 3 cycles2
Fines, 3 years$7,045
Beds140
Inspection findings
Inspectors recorded 60 findings in the last three inspection cycles.
Each entry below is a requirement that inspectors found the home did not meet on that date, in the regulator's own English wording.
| Inspection date | Area | Requirement the home did not meet (official wording, in English) | Severity | Corrected |
|---|---|---|---|---|
| Aug 13, 2026 | Nursing and physician services | 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. (F0726) | No harm, but a risk of harm isolated · from a complaint | Corrected: Sep 1, 2026 |
| Aug 13, 2026 | Resident assessment and care planning | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F0656) | No harm, but a risk of harm isolated · from a complaint | Corrected: Sep 1, 2026 |
| Aug 13, 2026 | Abuse, neglect and exploitation | Protect each resident from the wrongful use of the resident's belongings or money. (F0602) | No harm, but a risk of harm isolated · from a complaint | Corrected: Sep 1, 2026 |
| Jun 25, 2026 | Nursing and physician services | Ensure that the resident and his/her doctor meet face-to-face at all required visits. (F0712) | No harm, but a risk of harm pattern · from a complaint | Corrected: Aug 4, 2026 |
| Jun 25, 2026 | Nursing and physician services | Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. (F0711) | No harm, but a risk of harm pattern · from a complaint | Corrected: Aug 4, 2026 |
| May 8, 2026 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm isolated | Corrected: Jun 5, 2026 |
| May 8, 2026 | Pharmacy and medications | 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. (F0761) | No harm, but a risk of harm pattern | Corrected: Jun 5, 2026 |
| May 8, 2026 | Quality of life and care | Provide safe and appropriate respiratory care for a resident when needed. (F0695) | No harm, but a risk of harm isolated | Corrected: Jun 5, 2026 |
| May 8, 2026 | Quality of life and care | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689) | No harm, but a risk of harm isolated | Corrected: Jun 5, 2026 |
| May 8, 2026 | Quality of life and care | Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F0684) | No harm, but a risk of harm isolated | Corrected: Jun 5, 2026 |
| May 8, 2026 | Resident assessment and care planning | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F0656) | No harm, but a risk of harm pattern | Corrected: Jun 5, 2026 |
| May 8, 2026 | Resident assessment and care planning | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. (F0640) | No harm, but a risk of harm widespread | Corrected: Jun 5, 2026 |
| May 8, 2026 | Resident assessment and care planning | Assure that each resident’s assessment is updated at least once every 3 months. (F0638) | No harm, but a risk of harm pattern | Corrected: Jun 5, 2026 |
| May 8, 2026 | Resident assessment and care planning | Assess the resident when there is a significant change in condition (F0637) | No harm, but a risk of harm isolated | Corrected: Jun 5, 2026 |
| May 8, 2026 | Resident assessment and care planning | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (F0636) | No harm, but a risk of harm isolated | Corrected: Jun 5, 2026 |
| May 8, 2026 | Resident rights | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. (F0628) | No harm, but a risk of harm isolated | Corrected: Jun 5, 2026 |
| May 8, 2026 | Abuse, neglect and exploitation | Respond appropriately to all alleged violations. (F0610) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jun 5, 2026 |
| May 8, 2026 | Abuse, neglect and exploitation | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F0609) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jun 5, 2026 |
Earlier inspections (42)
| Inspection date | Area | Requirement the home did not meet (official wording, in English) | Severity | Corrected |
|---|---|---|---|---|
| Jan 28, 2026 | Resident assessment and care planning | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (F0657) | No harm, but a risk of harm isolated · from a complaint | Corrected: Mar 5, 2026 |
| Jan 28, 2026 | Resident assessment and care planning | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F0656) | No harm, but a risk of harm isolated · from a complaint | Corrected: Mar 5, 2026 |
| Jun 4, 2025 | Quality of life and care | Provide medically-related social services to help each resident achieve the highest possible quality of life. (F0745) | No harm, but a risk of harm pattern · from a complaint | Corrected: Jul 2, 2025 |
| May 19, 2025 | Resident rights | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. (F0557) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jul 2, 2025 |
| Oct 17, 2024 | Building and environment | Have policies on smoking. (F0926) | No harm, but a risk of harm pattern | Corrected: Nov 17, 2024 |
| Oct 17, 2024 | Building and environment | Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. (F0911) | No harm, minimal risk pattern | Corrected: Nov 17, 2024 |
| Oct 17, 2024 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm pattern | Corrected: Nov 17, 2024 |
| Oct 17, 2024 | Administration | Provide timely, quality laboratory services/tests to meet the needs of residents. (F0770) | No harm, but a risk of harm isolated | Corrected: Nov 17, 2024 |
| Oct 17, 2024 | Quality of life and care | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689) | No harm, but a risk of harm isolated | Corrected: Nov 17, 2024 |
| Oct 17, 2024 | Resident assessment and care planning | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. (F0644) | No harm, but a risk of harm isolated | Corrected: Nov 17, 2024 |
| Oct 17, 2024 | Resident assessment and care planning | Ensure each resident receives an accurate assessment. (F0641) | No harm, but a risk of harm isolated | Corrected: Nov 17, 2024 |
| Oct 17, 2024 | Resident assessment and care planning | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. (F0640) | No harm, but a risk of harm isolated | Corrected: Nov 17, 2024 |
| Aug 5, 2024 | Nursing and physician services | 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. (F0726) | No harm, but a risk of harm pattern · from a complaint | Corrected: Sep 5, 2024 |
| Jun 7, 2024 | Quality of life and care | Provide medically-related social services to help each resident achieve the highest possible quality of life. (F0745) | No harm, but a risk of harm isolated · from a complaint | Corrected: Jul 5, 2024 |
| Apr 11, 2024 | Quality of life and care | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689) | No harm, but a risk of harm isolated · from a complaint | Corrected: May 10, 2024 |
| Apr 11, 2024 | Abuse, neglect and exploitation | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F0609) | No harm, but a risk of harm isolated · from a complaint | Corrected: May 10, 2024 |
| Jan 11, 2024 | Building and environment | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. (F0921) | No harm, but a risk of harm pattern · from a complaint | Corrected: Mar 21, 2024 |
| Jan 11, 2024 | Building and environment | Make sure that a working call system is available in each resident's bathroom and bathing area. (F0919) | No harm, but a risk of harm widespread · from a complaint | Corrected: Mar 21, 2024 |
| Jan 11, 2024 | Building and environment | Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. (F0911) | No harm, but a risk of harm isolated · from a complaint | Corrected: Mar 21, 2024 |
| Jan 11, 2024 | Administration | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (F0867) | No harm, but a risk of harm widespread · from a complaint | Corrected: Mar 21, 2024 |
| Jan 11, 2024 | Quality of life and care | Provide or get specialized rehabilitative services as required for a resident. (F0825) | No harm, but a risk of harm isolated · from a complaint | Corrected: Mar 21, 2024 |
| Jan 11, 2024 | Quality of life and care | Provide enough food/fluids to maintain a resident's health. (F0692) | Actual harm to a resident isolated · from a complaint | Corrected: Mar 21, 2024 |
| Jan 11, 2024 | Quality of life and care | 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. (F0688) | No harm, but a risk of harm widespread · from a complaint | Corrected: Mar 21, 2024 |
| Jan 11, 2024 | Resident assessment and care planning | Assess the resident when there is a significant change in condition (F0637) | No harm, but a risk of harm isolated · from a complaint | Corrected: Mar 21, 2024 |
| Jan 11, 2024 | Abuse, neglect and exploitation | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F0609) | No harm, but a risk of harm isolated · from a complaint | Corrected: Mar 21, 2024 |
| Jan 11, 2024 | Resident rights | Reasonably accommodate the needs and preferences of each resident. (F0558) | No harm, but a risk of harm isolated · from a complaint | Corrected: Mar 21, 2024 |
| Jan 11, 2024 | Resident rights | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F0550) | No harm, but a risk of harm isolated · from a complaint | Corrected: Mar 21, 2024 |
| Jan 3, 2024 | Quality of life and care | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689) | No harm, but a risk of harm pattern · from a complaint | Corrected: Mar 18, 2024 |
| Jan 3, 2024 | Abuse, neglect and exploitation | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F0609) | No harm, but a risk of harm pattern · from a complaint | Corrected: Mar 18, 2024 |
| Dec 3, 2021 | Building and environment | Keep all essential equipment working safely. (F0908) | No harm, but a risk of harm isolated | Corrected: Jan 28, 2022 |
| Dec 3, 2021 | Infection control | Provide and implement an infection prevention and control program. (F0880) | No harm, but a risk of harm pattern | Corrected: Mar 10, 2022 |
| Dec 3, 2021 | Food and nutrition | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F0812) | No harm, but a risk of harm isolated | Corrected: Jan 28, 2022 |
| Dec 3, 2021 | Food and nutrition | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. (F0804) | No harm, but a risk of harm isolated | Corrected: Jan 28, 2022 |
| Dec 3, 2021 | Food and nutrition | 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. (F0803) | No harm, but a risk of harm pattern | Corrected: Jan 28, 2022 |
| Dec 3, 2021 | Food and nutrition | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. (F0802) | No harm, but a risk of harm pattern | Corrected: Mar 10, 2022 |
| Dec 3, 2021 | Pharmacy and medications | 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. (F0761) | No harm, but a risk of harm pattern | Corrected: Mar 10, 2022 |
| Dec 3, 2021 | Pharmacy and medications | Ensure that residents are free from significant medication errors. (F0760) | No harm, but a risk of harm isolated | Corrected: Mar 10, 2022 |
| Dec 3, 2021 | Pharmacy and medications | Ensure medication error rates are not 5 percent or greater. (F0759) | No harm, but a risk of harm pattern | Corrected: Mar 10, 2022 |
| Dec 3, 2021 | Pharmacy and medications | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F0755) | No harm, but a risk of harm isolated | Corrected: Mar 10, 2022 |
| Dec 3, 2021 | Quality of life and care | Provide enough food/fluids to maintain a resident's health. (F0692) | Actual harm to a resident isolated | Corrected: Jan 28, 2022 |
| Dec 3, 2021 | Quality of life and care | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689) | No harm, but a risk of harm pattern | Corrected: Jan 28, 2022 |
| Dec 3, 2021 | Quality of life and care | Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F0684) | No harm, but a risk of harm pattern | Corrected: Jan 28, 2022 |
Fines and payment denials
Federal fines in the last three years: $7,045 (1). Payment denials: 0.
| Date | Type | Amount |
|---|---|---|
| Jan 3, 2024 | Fine | $7,045 |
Staffing
| Nurse staff hours per resident per day | 3.38 | California median: 4.27 |
| Registered nurse hours per resident per day | 0.43 | California median: 0.52 |
| Nurse staff hours on weekends | 2.79 | California median: 3.85 |
| Nursing staff who left within a year | 34.6% | California median: 36.0% |
About this home
| Beds | 140 |
| Residents per day, average | 121.0 |
| Ownership | For-profit, limited liability company |
| Legal business name | Millbrae Care Center LLC |
| In Medicare/Medicaid since | Oct 24, 1969 |
Questions to ask when you call
- What was corrected after the last inspection?
- How many staff work at night and on weekends?
- Does anyone on staff speak my relative's language?
- May I visit at any time, without an appointment?
Source. Medicare Care Compare (CMS Provider Data), data dated Oct 1, 2026. Open this home on Medicare.gov