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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600135
Report Date: 10/18/2023
Date Signed: 10/18/2023 11:02:58 AM

Document Has Been Signed on 10/18/2023 11:02 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:
10/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Scott EvansTIME COMPLETED:
11:15 AM
NARRATIVE
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On October 18, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit in relation to the case-management visit that was conducted on 9/22/2023. LPA met with Administrator, Scott Evans and explained the purpose of the visit.

During the investigation conducted by the Department, it was revealed that Staff 1 (S1) had a clerical/administrative position while being employed at the facility. Based on documentation reviewed, S1 did not have any formal caregiving training to be able to provide care to residents at the facility. In addition, Staff 2 (S2) and Staff 3 (S3) acknowledged that S1 did not have any formal training in caregiving duties.

During the investigation, it was also discovered that S1 required a criminal record exemption in October of 2020, however failed to complete the exemption process by January of 2021. S1 was disassociated from the facility on 1/12/2022 but continued to work in the facility until S1’s resignation on June 1, 2023.

According to the staff interviewed, on May 27, 2023, the NOC shift had a last-minute call off and S1 offered to work overtime. S2 and S3 approved S1’s request for overtime as a last-minute caregiver to ensure the facility had enough staff for the night, however due to S1’s lack of training and caregiving experience, S1 was instructed to contact other caregivers on shift if a resident needed assistance.

According to the Administrator, there are usually 3-4 NOC shift staff members, but on the evening of May 27, 2023 to the morning of May 28, 2023, there were only three staff members; S1, Staff 4 (S4) and Staff 5 (S5). During this shift, S4 only saw S1 when he/she arrived to work and denied having any further interaction with S1 the rest of his/her shift. S1 and S5 went to three resident rooms to provide incontinence care together, however at 3:18am, S1 was observed entering Resident 1’s (R1’s) room alone.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with Administrator; a copy of the report is provided with appeal rights. Copy of civil penalty is provided
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 10/18/2023 11:02 AM - It Cannot Be Edited


Created By: Komal Charitra On 10/18/2023 at 10:20 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: 10/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
10/19/2023
Section Cited
CCR
87411(a)

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87411 Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…

Violation of this regulation is not met as evidenced by:
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Licensee/Administrator will submit a plan in writing describing how facility will ensure sufficient staff throughout the day and ensuring staff are trained for assigned duties.
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Based on documentation reviewed, and interviews conducted, it was acknowledged by the administrator that there are normally 3-4 caregivers that work NOC shift, however the night of 5/27/2023, there were only three staff members, one of which comprised of one administrative/clerical staff.

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Licensee/Administrator submitted an updated LIC500 to LPA
Deficiency Dismissed
Type A
10/19/2023
Section Cited
CCR87411(d)

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87411 Personnel Requirements - General: (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:

Violation of this regulation is evidenced by:
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Licensee/Administrator will submit a plan in writing to ensure current staff training includes; resident rights, assistance with ADLs, etc.
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Based on interviews conducted and documentation reviewed, S2 and S3 acknowledged that S1 did not have any formal caregiving training and lacked caregiving experience, however S1 was approved by S2 and S3 for overtime as a last-minute caregiver during the NOC shift on 5/27/2023.
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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: 10/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/18/2023 11:02 AM - It Cannot Be Edited


Created By: Komal Charitra On 10/18/2023 at 10:24 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: 10/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/19/2023
Section Cited
CCR
87405(h)

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87405 Administrator - Qualifications and Duties: (h) The administrator shall have the responsibility to: (3) Develop an administrative plan and procedures to ensure clear definition of lines of responsibility, equitable workloads, and adequate supervision.

Violation of this regulation is not met as evidenced by:
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Administrator will submit a plan in writing to ensure that staff members assigned specific duties continue to provide their assigned job.
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Based on interviews conducted and documentation reviewed, S1 did not have any formal caregiving training to be able to provide care to residents at the facility, however approved to be a last-minute caregiver without adequate supervision. Nevertheless, S1 was able to sexually abuse R1 and R2 during his/her NOC shift on 5/27/2023.
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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: 10/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2023


LIC809 (FAS) - (06/04)
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