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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600135
Report Date: 07/05/2022
Date Signed: 07/05/2022 03:24:36 PM


Document Has Been Signed on 07/05/2022 03:24 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
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: 115DATE:
07/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Activities Director, Kathleen SullivanTIME COMPLETED:
03:35 PM
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On July 5, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on Death Report submitted to CCL Office on 6/28/22. LPA met with Activities Director, Kathleen Sullivan and explained the purpose of the visit.

The Licensee reported on June 22, 2022, Resident 1(R1) was found in the bathroom floor faced down. According to the Licensee, R1 tried to ambulate with his/her walker but lost balance. R1 was found by a Med-Tech and was transported to the hospital shortly thereafter.

During the visit, LPA observed R1's room, reviewed R1's file, and interviewed staff members. According to file reviewed and staff interviewed, R1 is an assisted living resident and has been a resident at the facility for 3 years. Interviewed staff indicated that R1 does not have a falling history and will call for help when he/she needed anything.

According to interviewed staff, the day of the incident, R1 was alert and responsive during breakfast around 8:30am and at 10:20am, staff responded to R1's call. According to the Med-Tech who was present at the time of the incident, between 11:15am and 11:30am, R1 was found on the bathroom floor mumbling and semi-responsive. Med-tech immediately called 911.

Facility records document that R1 is an assisted living resident and did require assistance with daily living activities, however R1 was able to express himself/herself. According to staff, assisted living residents get checked on every meal time unless resident's notify staff otherwise. No findings of foul play or fault were found by the facility.

No citations were issued during the visit.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2022
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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