<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601052
Report Date: 04/18/2024
Date Signed: 04/18/2024 04:41:46 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
01/05/2024 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240105152428
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: 36DATE:
04/18/2024
UNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Bernadette KangTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained unexplained bruises while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 4/18/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Resident Care Coordinator, Bernadette Kang and explained the purpose of today's visit.

Regarding the allegation of Resident sustained unexplained bruises while in care. Reporting party (RP) states that staff blame RP for the bruises, but RP wants the facility to investigate if the bruising is caused by facility staff.

LPA interviewed two staff members who provide care for R1, and both confirmed that resident is combative and hits them when provided care. LPA also interviewed one witness (W1) and confirmed that R1 was being roughly handled by a visitor and but not by staff. R1s doctor (PCP) was also interviewed, and it was mentioned that the bruises can be normal and related to aging as well as other medical problems. It may also be due to non-benign causes. There were no bruises on the face, chest, bottom, or other areas that would highly raise concern for abuse.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 14-AS-20240105152428
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SILVER OAKS
FACILITY NUMBER: 415601052
VISIT DATE: 04/18/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on record reviews, there were several incident reports submitted by facility to Licensing documenting discoloration of skin on R1. Along with these reports are witness accounts where R1 was rough handled by a visitor. R1s recent needs and services plan includes full assistance due to R1 being combative and fighting staff when being aided with activities of daily living. Staff were also trained and re-trained for Patient Transfer and Activities of Daily Living. R1s medication list was reviewed and none of it may cause the resident to easily bruise.

Therefore, based on interviews & records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Report is reviewed and copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2