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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600689
Report Date: 08/05/2024
Date Signed: 08/05/2024 06:46:12 PM


Document Has Been Signed on 08/05/2024 06:46 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:STRATFORD, THEFACILITY NUMBER:
415600689
ADMINISTRATOR:CAMILLE CHRISTIEFACILITY TYPE:
741
ADDRESS:601 LAUREL AVETELEPHONE:
(650) 342-4106
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:96CENSUS: 78DATE:
08/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Lori Wolfe and Janie WooTIME COMPLETED:
07:00 PM
NARRATIVE
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During complaint investigation, LPA Jeung observed a deficiency of the California Code of Regulations, Title 22. Deficiency is cited on a following page.

According to Section 3.1.3.1. of facility's Continuing Care Residence Agreement, medication management is an assisted living service, and the provision of such service by facility is subject to a determination by the facility of the appropriateness or need for the service upon consultation with the resident or legal representative and his/her physician. In addition, the facility will determine "the extent of any services to be provided, and the proper setting."
In at least 4 cases, the facility failed to adhere to Section 3.1.3.1., and implemented the storage and administration of residents' medications without first consulting the residents AND their physicians. Staff managed medications for client #5 for 4 weeks, for client #2 for 4 weeks, for client #3 for 10 weeks, for client #7 for over 25 weeks. Only when written MD authorizations were obtained did facility relinquish medications and management services to respective spouses.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024
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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Document Has Been Signed on 08/05/2024 06:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: STRATFORD, THE
FACILITY NUMBER: 415600689

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/19/2024
Section Cited
CCR
87468.1(a)(16)

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PERSONAL RIGHTS
Residents in all RCFEs shall have the right to receive or reject medical care or other services. This requirement was not met, as facility failed to follow their own policies and procedures regarding provision of assisted living services, which posed a potential health, safety or
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Proof of correction shall be submitted to CCLD BY DUE DATE.
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personal rights risk to residents in care.
Residents' physicians were not consulted when facility assumed responsibility for medication management.
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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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024
LIC809 (FAS) - (06/04)
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