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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600135
Report Date: 05/17/2024
Date Signed: 05/17/2024 03:30:57 PM

Document Has Been Signed on 05/17/2024 03:30 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:SAN CARLOS ELMSFACILITY NUMBER:
415600135
ADMINISTRATOR/
DIRECTOR:		EVANS, SCOTTFACILITY TYPE:
740
ADDRESS:707 ELM STREETTELEPHONE:
(650) 595-1500
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY: 130CENSUS: 109DATE:
05/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:24 PM
MET WITH:Maribel Carino & Kirstin MarcosTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 5/17/24, LPA Grace Donato made an unannounced case management incident visit. LPA met with Director of Health Services (DHS), Maribel Carino & Associate Director of Operations (ADO), Kristin Marcos. LPA explained the purpose of the visit.

On 5/14/24, Desk Duty officer received a call from facility that a resident (R1) has passed. R1 was found by staff deceased in the bathroom. R1 appeared to have hung himself/herself in the shower pole. ADO was called and checked on the pulse to confirm death. 911 was called. R1 did not have any suicidal ideations and lives in assisted living. There was a suicide note that was left by R1 in the room. No signs of foul play.

No deficiencies cited today. Report is reviewed and copy is provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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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