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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600135
Report Date: 12/29/2023
Date Signed: 12/29/2023 11:04:45 AM

Document Has Been Signed on 12/29/2023 11:04 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: 110DATE:
12/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Activities Director, Kathleen SullivanTIME COMPLETED:
11:15 AM
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On December 29, 2023, Licensing Program Analyst (LPA) Komal Charitra met with Activities Director, Kathleen Sullivan for a Case Management visit to follow up on a substantiated allegation from an incident that occurred on May 28, 2023, regarding two residents; Resident 1 (R1) and Resident 2 (R2) who were physically abused by a staff member (S1).

On September 22, 2023, the Department concluded an investigation which alleged that S1 physically abused R1 and R2 on May 28, 2023. The allegation of physical abuse was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § “87468.1(a)(2)” Personal Rights of Residents in All Facilities.

The investigation revealed that S1 is a clerical/administrative staff member with no formal training in caregiving duties. S1 also failed to complete the criminal record exemption process after an arrest and was disassociated from the facility in 2021 but continued to work in the facility until their resignation on June 1, 2023.

On May 27, 2023, the night shift had a last-minute call-off and S1 overheard the staffing concern and offered to volunteer to stay for overtime. Staff 2 (S2) and Staff 3 (S3) approved S1’s request for overtime as a last-minute caregiver to cover for the call-off for the night shift. According to the administrator, there are usually four staff members for the night shift, 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 they arrived to work and denied having any further interaction with S1 the rest of the shift. During S5’s shift, S5 recalled that S1 and S5 went to three residents to offer incontinence care (diaper changes) at around 1:35 a.m., R1 was one of the residents but declined care. S5 denied seeing S1 after 3:00 a.m. R1 has a camera inside their room and camera footage captured S1 (identified by the administrator) entering R1’s room alone at 3:18 a.m. (Cont. to 809C).

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2023
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: 12/29/2023
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The next day on May 28, 2023, both R1 and R2 reported that they felt someone come into their room and orally copulated them during the night. R1 and R2 do not know each other. R1 stated that they repeatedly told the abuser to stop the assault. R2 stated that no permission was given, it was unwanted and felt very embarrassed by the incident.

At the time of the case-management visit conducted on September 22, 2023, an immediate civil penalty of $500 was issued. The Licensee was informed that an additional civil penalty was being determined and might be assessed based on Health and Safety Code § 1569.49

The Department has concluded an analysis and has determined that an additional civil penalty is warranted for a violation that resulted in R1 and R2 being physically abused by S1 while under the care of this facility. Physical abuse is defined by Welfare & Institutions Code section 15610.63 includes assault, battery, assault with a deadly weapon, force likely to produce great bodily injury, unreasonable physical constraint or prolonged or continual deprivation of food or water, sexual assault, and use of a physical or chemical restraint or psychotropic medication in certain conditions. This is evidenced by the Licensee failing to provide proper care and supervision which resulted in R1 and R2 being physically abused.

Today, December 29, 2023, the Department is issuing a civil penalty per Health and Safety Code 1569.49 for a violation that the Department constitutes as physical abuse in the amount of $20,000.00 ($10,000.00 for each physical abuse of a resident). However, since an immediate civil penalty of $500.00 was previously issued on September 22, 2023, the amount of the civil penalty issued today will be $19,500.00.

A copy of the LIC 421D was given to Activities Director, Kathleen Sullivan and originals were signed.

Exit interview conducted with Activities Director. A copy of the report issued. Appeal rights provided. Kathleen Sullivan's signature on this report acknowledges receipt of the appeal rights., found on page two of the LIC 421D.

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023
LIC809 (FAS) - (06/04)
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