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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600223
Report Date: 10/08/2020
Date Signed: 10/12/2020 10:04:09 AM

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:STERLING COURTFACILITY NUMBER:
415600223
ADMINISTRATOR:CHARLES, SARAH ST.FACILITY TYPE:
740
ADDRESS:850 NO. EL CAMINO REALTELEPHONE:
(650) 344-8200
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:24CENSUS: 13DATE:
10/08/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Novie Villafuerte and Sarah St. CharlesTIME COMPLETED:
12:00 PM
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In response to Incident Report received on 10/2/20 regarding client in room 117, LPA Jeung conducted virtual case management visit via FaceTime. LPA observed newly installed audio alerts on the main front entry door of facility and rear double doors in the assisted living unit. When the doors open, an audio alert is emitted at the front reception desk for the front door and in the assisted living dining room for the rear door in assisted living. LPA also observed a camera at the front reception area and monitor at the reception desk. Room 117 was toured, and LPA observed resident having lunch in the room.

Ms. St. Charles advised that staff will receive additional training on appropriate monitoring of the front door and camera monitor, as well as staff response to the auditory alarms on exit doors. Documentation of training will be maintained and be available upon request.

LPA is in receipt of client's MD report dated 11/19. LPA recommended that MD report be updated, and for facility to re-assess client and complete new Needs and Services Plan and Appraisal. In addition, client's medications have been adjusted recently, and is prescribed medications by both her primary care MD and psychiatrist. LPA advised that facility list all client's medications and provide this to MD and psychiatrist in order to re-evaluate her medications.

Client was not injured as a result of incident on 9/30/20. No deficiencies cited today.

***************This report is emailed to Ms. St. Charles for signature. Signed report to be emailed to LPA
or faxed to 650/266-8841. *******************************



SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020
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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