Your report for Millbrae Care Center
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- CaliforniaAbove only 16% of peers1,154 rated homes · average 3.2★
- San Mateo CountyAbove only 15% of peers14 rated homes · average 3.6★
- United StatesAbove only 20% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point2★−0.8 vs CA avg
- StaffingCan add or remove a star3★−0.1 vs CA avg
- Quality measuresCan add or remove a star2★−2.1 vs CA avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersCA avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 27% of peersCA avg3.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments2★Above only 2% of peersCA avg4.1★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.26hrsAbove only 2% of peersCA avg4.51Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.50hrsAbove 52% of peersCA avg0.65Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better38%Above only 49% of peersCA avg38%RN turnover40%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$7,045Above only 41% of peersCA avg$26,970Fines · denials1 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthJul 2019 – Jun 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Jun 4, 2025Cycle 1worst E · no actual harm
- F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Quality of Life and CareE · patternCorrected Jul 2, 2025
May 19, 2025Cycle 1worst D · no actual harm
- F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Resident RightsD · isolatedCorrected Jul 2, 2025
Oct 17, 2024Cycle 1worst E · no actual harm
- F911Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.EnvironmentalB · patternCorrected Nov 17, 2024
- F926Have policies on smoking.EnvironmentalE · patternCorrected Nov 17, 2024
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningD · isolatedCorrected Nov 17, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Nov 17, 2024
- F770Provide timely, quality laboratory services/tests to meet the needs of residents.AdministrationD · isolatedCorrected Nov 17, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Nov 17, 2024
- Encode each residentâs assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care PlanningD · isolatedCorrected Nov 17, 2024
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Nov 17, 2024
Aug 5, 2024Cycle 2worst E · no actual harm
- F726Ensure 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 ServicesE · patternCorrected Sep 5, 2024
Jun 7, 2024Cycle 2worst D · no actual harm
- F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Quality of Life and CareD · isolatedCorrected Jul 5, 2024
Apr 11, 2024Cycle 2worst D · no actual harm
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 10, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected May 10, 2024
Jan 11, 2024Cycle 3worst G · actual harm$7,045
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Mar 21, 2024
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrected Mar 21, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 21, 2024
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Mar 21, 2024
- F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalF · widespreadCorrected Mar 21, 2024
- F911Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.EnvironmentalD · isolatedCorrected Mar 21, 2024
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationF · widespreadCorrected Mar 21, 2024
- F825Provide or get specialized rehabilitative services as required for a resident.Quality of Life and CareD · isolatedCorrected Mar 21, 2024
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Mar 21, 2024
- F688Provide 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 CareF · widespreadCorrected Mar 21, 2024
- F637Assess the resident when there is a significant change in conditionResident Assessment and Care PlanningD · isolatedCorrected Mar 21, 2024
Jan 3, 2024Cycle 3worst E · no actual harm$7,045
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Mar 18, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Mar 18, 2024
Aug 24, 2023Cycle 3worst D · no actual harm
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Sep 28, 2023
- F656Develop 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 PlanningD · isolatedCorrected Sep 28, 2023
Aug 2, 2023Cycle 3worst D · no actual harm
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 18, 2023
Jul 19, 2023Cycle 3worst D · no actual harm
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 28, 2023
Jun 28, 2023Cycle 3worst D · no actual harm
- F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Aug 2, 2023
Apr 13, 2023Cycle 3worst D · no actual harm
- F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 28, 2023
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 28, 2023
Mar 30, 2023Cycle 3worst D · no actual harm
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 8, 2023
Feb 16, 2023Cycle 3worst D · no actual harm
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Apr 3, 2023
Feb 15, 2023Cycle 3worst D · no actual harm
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Mar 27, 2023
- F585Honor 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 RightsD · isolatedCorrected Mar 31, 2023
Feb 14, 2023Cycle 3worst E · no actual harm
- F940Develop, implement, and/or maintain an effective training program for all new and existing staff members.AdministrationE · patternCorrected Mar 29, 2023
- F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Mar 29, 2023
- F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Resident RightsD · isolatedCorrected Mar 29, 2023
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalD · isolatedCorrected Mar 29, 2023
- F656Develop 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 PlanningD · isolatedCorrected Mar 29, 2023
Dec 3, 2021Cycle 2worst G · actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Jan 28, 2022
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryD · isolatedCorrected Jan 28, 2022
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryD · isolatedCorrected Jan 28, 2022
- F803Ensure 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 DietaryE · patternCorrected Jan 28, 2022
- F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Nutrition and DietaryE · patternCorrected Mar 10, 2022
- F761Ensure 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 ServiceE · patternCorrected Mar 10, 2022
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Mar 10, 2022
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Mar 10, 2022
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Mar 10, 2022
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Jan 28, 2022
- F908Keep all essential equipment working safely.EnvironmentalD · isolatedCorrected Jan 28, 2022
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareE · patternCorrected Jan 28, 2022
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Mar 10, 2022
Jul 25, 2019Cycle 3worst F · no actual harm
- Encode each residentâs assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care PlanningD · isolatedCorrected Oct 3, 2019
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Oct 3, 2019
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Oct 3, 2019
- F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningD · isolatedCorrected Oct 3, 2019
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Oct 3, 2019
- F656Develop 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 PlanningD · isolatedCorrected Oct 3, 2019
- F688Provide 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 CareD · isolatedCorrected Oct 3, 2019
- F700Try 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 CareD · isolatedCorrected Oct 3, 2019
- F732Post nurse staffing information every day.Nursing and Physician ServicesD · isolatedCorrected Oct 3, 2019
- F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Quality of Life and CareD · isolatedCorrected Oct 3, 2019
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Oct 3, 2019
- F836Ensure 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.AdministrationF · widespreadCorrected Oct 3, 2019
- F840Employ 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.AdministrationD · isolatedCorrected Oct 3, 2019
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Oct 3, 2019
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalD · isolatedCorrected Oct 3, 2019
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.26hrs
- Registered nursesRN hours only0.50hrs
- Licensed practical nursesLPN hours0.93hrs
- Nurse aidesCNA hours1.83hrs
- Weekend nursingAll staff on Saturdays and Sundays2.94hrs
- California average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better38%Above only 49% of peersCA avg 38%
- RN turnoverRegistered nurses only40%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy140 certified beds · ~128 residents a day91%Above only 49% of peersCA avg 88%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $7,045In fines
- 1Fine
- 0Payment denials
- $26,970CA avg in fines
Actions on record
- Jan 3, 2024Civil money penalty$7,045
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- Independent
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Estrella Choy
- Ronald Mayer
- Asher Peretz
- Elsa Rodriguez
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 056122 · 33 MATEO AVENUE, MILLBRAE, CA, 94030.
- Percentiles compare this facility with every rated nursing home in California and San Mateo County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









