415601052-9-2-2023-14-AS-KHOS-CVKJJ4-20230911070456

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601052
Report Date: 09/01/2023
Date Signed: 09/02/2023 12:48:04 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/20/2023 and conducted by Evaluator Grace Donato

COMPLAINT CONTROL NUMBER: 14-AS-20230620110243

FACILITY NAME:	SILVER OAKS		FACILITY NUMBER:	415601052
ADMINISTRATOR:	OLLIE VANCE		FACILITY TYPE:	740
ADDRESS:	16 COLEMAN PLACE		TELEPHONE:	(650) 322-2022
CITY:	MENLO PARK	STATE: CA	ZIP CODE:	94025
CAPACITY:	43	CENSUS:	DATE:	09/01/2023
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:			TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Due to staff negligence, resident had multiple witnessed falls causing injury
Staff did not feed/give drink to the resident
Staff did not allow resident to have a visitor

INVESTIGATION FINDINGS:

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On 09/01/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegations. LPA met with Resident Care Coordinator Shayla Brewster and Administrator Ollie Vance followed after. LPA explained the purpose of the visit.

Regarding the allegation that staff did not feed/give drink to the resident (R1), according to the reporting party, they have a video showing staff being negligent to the resident. The food was placed in front of the resident and staff did not assist on feeding.

LPA interviewed six staff members. Record reviews and observations were also done. Six out of six staff members mentioned that residents do have a schedule for eating, three meals a day including three snacks in between. Asked what if residents don’t want to eat, staff tries to ask 3 times and would offer Ensure in the end to make sure residents are nourished. There are also 2 hydrations stations in the facility. Residents are offered and encouraged every hour to drink water or other beverages available. Other family members also bring in drinks which are given to residents. In cases where family members are in the facility during mealtimes, the family members have the option to have the staff assist them in feeding or do the feeding themselves for the residents.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20230620110243

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/01/2023

NARRATIVE

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LPA interviewed four family members of different residents and three of them mentioned that there were no issues with regards to feeding and hydrating the residents. However, one family member mentioned instances where resident wasn’t assisted during the time when family member visited. This instance was addressed by the family to the administrator. Four out of four residents were interviewed however not able to get some answers due to cognitive diagnosis.

Regarding the allegation that Staff did not allow resident to have a visitor, according to reporting party, the director yelled at RP and "banned" RP from seeing the resident and entering the facility.

Based on interviews and record reviews, the reporting party was told to leave the facility but was not banned. Since RP was violating personal rights of the resident, RP was asked to leave. RPs family member came back to the facility and was able to discharge the resident. RP did not know that he/she would be able to enter because he/she was not there the day the resident was discharged. Interviewed four residents but couldn’t get definitive answers due to cognitive diagnosis. LPA interviewed 4 family members and all of them confirmed that they can visit in the facility at any time with no issues.

Regarding the allegation that due to staff negligence, resident (R1) had multiple witnessed falls causing injury, according to reporting party, R1 had multiple falls causing bruises on R1s shins, face, elbows, arms, and legs.

Based on interviews and record reviews, these incidents were submitted to CCLD. R1 had only two falls that were reported. These were reported to CCLD, PCP, and responsible party. Facility reassessed R1 but couldn’t have these signed and filed due to R1 being discharged from the facility. Facility protocol for falls include calling 911 if needed, reassess residents, and work with family members for reappraisal to address resident needs. These reappraisals help with the decision if residents would need a higher level of care.

Therefore, based on the interviews conducted, files reviewed, and information collected, the above allegations are found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Report is reviewed with Administrator; Ollie Vance and a copy is provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC9099 (FAS) - (06/04)

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