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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508815
Report Date: 11/05/2024
Date Signed: 02/12/2026 12:56:08 PM

Document Has Been Signed on 02/12/2026 12:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:FHAR - SNEATH LANE HOMEFACILITY NUMBER:
410508815
ADMINISTRATOR/
DIRECTOR:		SURDEL, PHILFACILITY TYPE:
735
ADDRESS:3600 SNEATH LANETELEPHONE:
(650) 589-6152
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 6DATE:
11/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Phil SurdelTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
NARRATIVE
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 *** THIS IS AN AMENDED REPORT CORRECTING PAGE 2 AT LINE 27 ***

On November 5, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to deliver an investigation finding of an incident that was report by the facility. LPA met with administrator and explained the purpose of today’s visit.

On August 19, 2024, facility report to CCL that on 8/18/2024, resident #1 (R1)’s responsible party reported to the facility that R1 sustained two fractured ribs on the left side of R1’s body and the report indicated that there was an incident that happened on 8/15/2024 involving R1 and staff #1 (S1) may have resulted in R1’s injury.

During the investigation, the Department interviewed residents, facility staff, administrator, responsible party and reviewed documents.

According to R1, S1 told him/her to take a shower and he/she got nervous and punched S1. Subsequently, S1 pushed and hit R1 which resulted R1 fell onto the bed post in R1's bedroom and R1's body hit the bed post.

According to S1, on 8/15/2024, S1 told R1 to get ready for a shower and approximately, 10-15 minutes later, S1 went to check on R1 and R1 turned around and hit S1 and S1 pushed R1 aside to the left that resulted R1 falling at the foot of the bed onto the floor. S1 reported it the incident to staff #2(S2).

According to S2, on 8/15/2024, S1 asked for a pack of ice for R1's hand but never told what actually happened to R1. Subsequently, S1 and S2 went to talk to R1 but did not assess R1. On the next day, when S2 returned to work, S2 did not check on R1's condition.

According to staff #3(S3), on 8/15/2024, he/she observed R1 was in pain when taking a breath, walking and urinating throughout the day but S3 did not report it to anyone.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: FHAR - SNEATH LANE HOME
FACILITY NUMBER: 410508815
VISIT DATE: 11/05/2024
NARRATIVE
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According to staff #4 (S4), on 8/15/2024, he/she was notified of an incident that happened to R1 and on the next day, S4 observed R1 was complaining of back pain and S4 decided to have R1 to stay home instead of attending the day program and reported his/her observation to the facility manager who did not respond until the facility manager was notified by R1's responsible party of R1's injuries.

According to the administrator, he was notified of the incident from R1's responsible party and not the facility staff.

Based on interviews, observations and record reviews, this incident has been substantiated as S1 hit and pushed a resident who had a behavior episode which resulted R1 sustaining two fracture ribs, the facility did not seek medical attention for R1, the facility staff and manager did not report the incident to the administrator, and the facility staff did not check on R1 when R1 was observed to be in pain and verbalized of having pain.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in additional civil penalties.

AN IMMEDIATE CIVIL PENALTY OF $1000 WAS ASSESSED TODAY: $500 FOR THE VIOLATION RESULTED INJURY TO A CLIENT AND $500 FOR THE VIOLATION AS STAFF DID NOT SEEK MEDICAL ATTENTION FOR A CLIENT.

THE ADMINISTRATOR WAS INFORMED THAT AN ADDITIONAL CIVIL PENALTY IS STILL BEING DETERMINED AND MIGHT BE ASSESSED BASED ON HEALTH AND SAFETY CODE §1548(f)(1)(A).

This report is reviewed and discussed with the administrator.

A copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2024 10:27 AM - It Cannot Be Edited


Created By: Murial Han On 11/05/2024 at 09:46 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FHAR - SNEATH LANE HOME
FACILITY NUMBER: 410508815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2024
Section Cited
CCR
80072(a)(3)

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80072 Personal Rights..(a)Except for children’s residential facilities, each client shall have personal rights which include,..(3) To be free from corporal or unusual punishment, infliction of pain,...
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The administrator shall develop a plan in writing on how to prevent this from happening again and the plan shall include staff in-service on Title 22 85165 - Emergency Intervention in Adult Residential Facilities.
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This requirement is not met as evidenced by based on interviews, and observation, S1 hit and pushed R1 resulted R1 sustaining two fracture ribs which poses an immediate health and safety risks to residents in care
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The administrator will provide a copy of the plan to CCL by 11/6/2024.

Civil penalty in the amount of $500 is being assessed today.
Type A
11/06/2024
Section Cited
CCR80075(a)

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80075 Health Related Services
(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services,...
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The administrator shall develop a plan in writing to prevent this from happening again and the plan shall indicate staff training. The administrator will provide a copy of the plan to CCL by 11/6/2024.
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The requirement is not met as evidenced by based on interviews, observation, and record reviews S1 hit and pushed R1 on 8/15/2024, R1 was complaining and observed by staff of having pain while walking, urinating, etc. and the facility did not seek medical attention for R1 which poses an immediate health risks to residents in care.
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Civil penalty in the amount of $500 is being assessed today as the failure to arrange medical treatment for Resident 1 (R1) after an incident that resulted in two fracture ribs.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024


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Document Has Been Signed on 11/05/2024 10:27 AM - It Cannot Be Edited


Created By: Murial Han On 11/05/2024 at 09:49 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FHAR - SNEATH LANE HOME
FACILITY NUMBER: 410508815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2024
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision ( a) The licensee shall provide care and supervision as necessary to meet the client's needs.
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The administrator shall develop a plan in writing to indicate what the facility will do moving forward to prevent this from happening again and the plan shall indicate staff training.
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The requirement is not met as evidenced by based on interviews, observation, and record review, on 8/15/2024, R1 was pushed and hit by S1 and R1 was verbalizing of having pain. However, facility staff did not check on R1 and did not report it to the administrator which poses an immediate health risks to residents in care.
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The administrator will provide a copy of the plan to CCL by 11/6/2024.
Type A
11/06/2024
Section Cited
CCR80065(f)(3)

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80065 Personnel Requirements..(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of..(3)Provision of client care and supervision, including communication. The requirement is not met as evidenced by:
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The administrator shall develop a plan in writing to ensure all staff are reporting/communicating of all the incidents that has occurred in a timely fashion and the plan shall include staff training.
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Based on interview, observation and record review, the facility staff and manager did not report/communicate to the administrator of an incident that happened on 8/15/2024 between R1 and S1 that resulted R1 sustaining two fracture ribs which poses an immediate health risk to residents in care.
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The administrator will provide a copy of the plan to CCL by 11/6/2024
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024


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