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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600135
Report Date: 09/22/2023
Date Signed: 09/22/2023 11:27:47 AM

Document Has Been Signed on 09/22/2023 11:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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: 114DATE:
09/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Scott Evans TIME COMPLETED:
11:45 AM
NARRATIVE
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On September 22, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit to follow up on a case management visit that was conducted on 6/6/2023. LPA met with Administrator, Scott Evans and explained the purpose of the visit.

On 6/6/2023, LPA conducted a case management visit to follow up on two incident reports. On 5/31/2023, Licensee reported that S1 allegedly sexually abused Resident 1 (R1) and Resident 2 (R2) on 5/28/2023. These incidents were referred to the Department’s Investigation Branch.

During the investigation, the Department’s Investigator conducted record review, reviewed R1 and R2’s files, conducted interviews and reviewed the police report. Based on the interviews conducted, S1 worked NOC shift on 5/27/2023 and was instructed to stay at the front desk and monitor call lights from assisted living residents due to lack of training. In addition, staff interviewed indicated that S1 was instructed that if a call light activated, S1 would radio or call the memory care caregivers to assist the resident.

According to Staff 2 (S2), the Memory Care Director who was on shift the day of the incident, it was acknowledged that S1 and S2 checked on R1 at around 1:35am, however R1 did not need any assistance. Camera footage observed shows S1 entering R1’s room alone at 3:18am. S2 denied being with S1 during this time.

Furthermore, when administrator, Scott Evans asked S1 if he/she had entered R2’s room, initially S1 denied this allegation, however changed his/her answer and admitted he/she did enter R2’s room. (CONT. TO 809C)
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SAN CARLOS ELMS
FACILITY NUMBER: 415600135
VISIT DATE: 09/22/2023
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During the investigation, it was also noted that S1 was disassociated from the facility on 01/12/2021. S1 required a criminal record exemption effective 10/29/2020 as the Department received additional or subsequent criminal record information and that S1 no longer has a criminal record clearance. S1 had failed to complete the exemption process putting residents health and safety in the facility at risk.

Deficiencies cited today under the California Code of Regulations, Title 22, Division 6, follows on LIC 9099D. An immediate civil penalty in the amount of $500 for a violation resulting in death and serious bodily injuries. The Licensee was informed that additional civil penalties may be assessed.

Report a reviewed with Administrator and a copy is provided with appeal rights. Civil penalties are also provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/22/2023 11:27 AM - It Cannot Be Edited


Created By: Komal Charitra On 09/22/2023 at 10:59 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: SAN CARLOS ELMS
FACILITY NUMBER: 415600135

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2023
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

Violation of this regulation is not met as evidenced by:
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Licensee/Administrator shall develop a plan of action in writing describing how the facility shall ensure personal rights of residents are observed by facility. Plan of correction to include plan to train staff.
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Based on the Department's interviews and record conducted, the Department found that S1 abused R1 and R2 which poses an immediate health and safety risk to residents in care.
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An immediate civil penalty in the amount of $500 for a violation resulting in death and serious bodily injuries. The Licensee was informed that additional civil penalties may be assessed.
Deficiency Dismissed
Type A
09/23/2023
Section Cited
CCR87355(e)(2)

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87355 Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or...

Violation of this regulation is not met evidenced by:
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Licensee/Administrator to submit a written plan describing how to ensure staff members maintain clearance, this includes routine audits.
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Based on record review, S1 was not observed to be associated to the facility.
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An immediate civil penalty of $1000.00 ($100/day x 10 days) will be issued today for S1.
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:Cara Smith
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/22/2023 11:27 AM - It Cannot Be Edited


Created By: Komal Charitra On 09/22/2023 at 11:16 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: SAN CARLOS ELMS
FACILITY NUMBER: 415600135

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/23/2023
Section Cited
CCR
87405(h)(1)

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87405 - Administrator - Qualifications and Duties: (h) The administrator shall have the responsibility to: (1) Administer the facility in accordance with these regulations and established policy, program and budget

Violation of this regulation is not met as evidenced by:
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Licensee shall develop a plan of action in writing describing how the facility shall ensure administrator performs duties and requirements according to regulations.
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The administrator failed submit to the Department a completed exemption request on S1’s behalf to allow S1 to continue to work, reside or be present in the facility with criminal record clearance. The administrator also failed to immediately remove him/her from the facility as S1 was disassociated from the facility effective 01/12/2021 and continued to be employed at the facility until S1’s resignation (last date worked) 05/30/2023.
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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:Cara Smith
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023


LIC809 (FAS) - (06/04)
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