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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600135
Report Date: 10/08/2020
Date Signed: 10/30/2020 12:27:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SAN CARLOS ELMSFACILITY NUMBER:
415600135
ADMINISTRATOR:EVANS, SCOTTFACILITY TYPE:
740
ADDRESS:707 ELM STREETTELEPHONE:
(650) 595-1500
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY:130CENSUS: 99DATE:
10/08/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Scott Evans TIME COMPLETED:
01:15 PM
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On October 8, 2020, Licensing Program Analyst (LPA) Buksh, conducted a visual inspection with Executive Director, Scott Evans. The inspection was conducted regarding the incident that occurred on September 28, 2020 and was reported to CCLD by the Executive Director.

It was reported that resident (R1) had eloped from the facility on September 28, 2020. She was not in her bedroom when checked at 9:20AM by a caregiver. Executive Director stated he received a call from Sheriff, asking about Resident (R1). They told R1 was found few blocks from the facility about a mile away. They were taking her to the hospital for medical evaluation. Executive Director stated R1 must have eloped from the side door as the staff at the front desk did not see R1 leave from front door. The alarms are not active from 8:30 am. He stated if R1 had left before, the alarm signal would go off. No injuries were noted. Facility re- assessed R1's care plan and R1 was moved to memory care from Assisted living. LPA discussed solutions with Executive Director. Executive Director would update their elopement plan and would share with CCLD. Facility is in process to re -assess and re-develop care plan for all residents in assisted living to ensure they should be in the assisted living or moved to memory care. Facility would provide additional in - service training to caregivers on elopement.

The inspection report was emailed to Executive Director for review and signature.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Shabana BukshTELEPHONE: (650) 266-8810
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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