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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601015
Report Date: 07/17/2023
Date Signed: 07/17/2023 03:17:29 PM


Document Has Been Signed on 07/17/2023 03:17 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:TROUSDALE, THEFACILITY NUMBER:
415601015
ADMINISTRATOR:CHU, SYLVIAFACILITY TYPE:
740
ADDRESS:1600 TROUSDALE DRTELEPHONE:
(650) 443-3700
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:140CENSUS: 118DATE:
07/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Preet Ghurman and Anne AquinoTIME COMPLETED:
03:30 PM
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LPA Jeung met with business services manager and memory care coordinator in response to Report of Suspected Abuse dated 5/22/23 regarding client #1 and private companion, and submitted to CCLD.

LPA was advised that private companion was removed from facility on 5/23/23. Based on wishes of family, private companion was allowed to resume companionship to client as of 5/31/23. It is unknown what, if any, additional training was provided to private companion by caregiver agency.

LPA reviewed file for client #1. In the admission agreement, pages 57, 58, 59 pertain to third party caregivers--Acknowledgement and Indemnification, Rules of Conduct for Third Party Caregivers--but the acknowledgement was not signed by the private companion, nor can it be confirmed that these documents were given to or acknowledged by private companion of client #1. This person also does not have criminal record clearance and association to facility.

LPA recommended that private attendants be required to acknowledge and sign Personal Rights forms LIC613C/LIC613C2 when providing services to facility clients.


Deficiency of the California Code of Regulations, Title 22 is cited on a following page.




SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
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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Document Has Been Signed on 07/17/2023 03:17 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: TROUSDALE, THE
FACILITY NUMBER: 415601015

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2023
Section Cited
CCR
87355(e)(2)

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CRIMINAL RECORD CLEARANCE
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility, request a transfer of a criminal record clearance as specified in Section 87355(c)
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Plan/proof of correction to be submitted to CCLD BY DUE DATE
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This requirement was not met, as staff 1, who is a private companion to client 1, does not have criminal record clearance associated to facility. Licensee failed to ensure that persons with client contact maintain criminal record clearance and association with facility, which poses a health, safety or personal rights risk.
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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
LIC809 (FAS) - (06/04)
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