415601052-8-23-2023-14-AS-KHOS-CVKJPZ-20230911071423

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601052
Report Date: 08/23/2023
Date Signed: 08/23/2023 04:05:57 PM

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
06/22/2023 and conducted by Evaluator Grace Donato

COMPLAINT CONTROL NUMBER: 14-AS-20230622161129

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: 34	DATE:	08/23/2023
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Ollie Vance, Shayla Brewster		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff do not prevent residents from being physically abused by other residents.
Staff do not inform resident's authorized representative of incidents as required.

INVESTIGATION FINDINGS:

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On 08/23/23, 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 do not prevent residents from being physically abused by other residents, according to the reporting party, Resident 1 (R1) & Resident 2 (R2) were admitted to the facility with abusive behaviors.

Interviews were conducted and five out of five family members all have the same observations that they haven’t seen any resident physically abuse another resident without a staff coming right away to either stop the residents or redirect them. While there might be occasions where residents become aggressive, staff member quickly get in the middle deter aggressions. Six out of six staff members have also mentioned that they redirect residents when aggressions start, if they can’t handle it on their own, they ask for more help. (CONT on 9099-C)

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20230622161129

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: 08/23/2023

NARRATIVE

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Regarding the allegation that staff do not inform resident's authorized representative of incidents as required, according to reporting party it’s the health care workers or other visitors who end up telling the authorized representatives about the incidents.

Based on interviews and record reviews, incident reports are reported to the responsible parties. Five out of five family members interviewed mentioned that they do receive reports regarding the residents. Family members would either receive a call, a text message, voicemail or email from the facility. Six out of six staff members also mentioned the process that they follow for reporting which is to report incidents to either the Med Techs, Care Coordinator or Administrator who in turn does the incident reports and also contact the responsible parties. A record review of incident reports submitted by the facility shows that facility has contacted responsible parties. In these reports also shows the action plans that facility would do regarding the resident.

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 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: 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

LIC9099 (FAS) - (06/04)

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