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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601052
Report Date: 08/23/2023
Date Signed: 08/23/2023 01:28:20 PM


Document Has Been Signed on 08/23/2023 01:28 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:SILVER OAKSFACILITY NUMBER:
415601052
ADMINISTRATOR:OLLIE VANCEFACILITY TYPE:
740
ADDRESS:16 COLEMAN PLACETELEPHONE:
(650) 322-2022
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:43CENSUS: 34DATE:
08/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Shayla Brewster, Ollie VanceTIME COMPLETED:
01:30 PM
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LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Resident Care Coordinator Shayla Brewster and Administrator Ollie Vance followed. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including a random sample of resident rooms, common areas & kitchen area. The indoor and outdoor passageways were free of obstruction. LPA observed some residents were in the dining hall having some breakfast. Hot water was also tested in the bathrooms and the temperature was 112 deg F. The residents have adequate number of linens and incontinence care items. All personal belongings are intact. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floors. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every quarter.

LPA reviewed five resident records and five staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic 20hr requirement. Facility has a certified administrator on site with complete certification and training requirements. Facility accepts hospice residents and follow the required waiver requirements.

Medication review was done, and three out of four resident records showed medications not logged. Facility updated the records right away.

LPA interviewed 4 residents and 4 staff members. Residents are happy and feel that they are well taken care of. Staff are very competent with regards to the care of the residents.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
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 08/23/2023 01:28 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: SILVER OAKS
FACILITY NUMBER: 415601052

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based onobservation and record review, the licensee did not comply with the section cited above due to three out of four resident records showed medications not logged which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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Licensee to submit plan of action, in-service training for staff regdarding Medication. Licensee to submit plan by POC due date 8/30/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: SILVER OAKS
FACILITY NUMBER: 415601052
VISIT DATE: 08/23/2023
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LPA requested licensee to submit the following and was received in the facility at 8/23/2023:

LIC 500 Personnel Report
Certificate of Liability Insurance
LIC 308
LIC 610D

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
LIC809 (FAS) - (06/04)
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