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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601052
Report Date: 09/20/2024
Date Signed: 09/20/2024 01:50:42 PM

Substantiated


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
07/18/2024 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240718122157
FACILITY NAME:SILVER OAKSFACILITY NUMBER:
415601052
ADMINISTRATOR:JOSHUA LAMBENGCOFACILITY TYPE:
740
ADDRESS:16 COLEMAN PLACETELEPHONE:
(650) 322-2022
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:43CENSUS: 38DATE:
09/20/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Administrator - Joshua Lambengco via facetimeTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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- Facility staff did not dispense medications as prescribed
INVESTIGATION FINDINGS:
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On 09/20/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the allegation received. LPA met with the administrator Joshua Lambengo via facetime and explained the purpose of today's visit.

During the course of the investigation LPA conducted interviews, reviewed documentation, and photographs related to the allegation. Per interviews conducted it was confirmed that the pharmacy only filled and sent the prescription antibiotic to the facility one time. There wasn't more than one order of the prescription sent to the facility per the pharmacy. Nurses made observations on three dates that the medication was not being dispensed as prescribed. This poses an immediate health and safety risk to residents in care. Based on these items the allegation is substantiated.

Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D. Report is reviewed with activities director Linda Mittelstadt and a copy is provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
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-20240718122157
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2024
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care - A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self administered medications as needed. This regulation has not been met as evidenced by:
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Licensee shall deveolop a plan of corrections to address and ensure that this regulation is met at all times. POC to be received by 09/21/2024
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Based on interviews conducted, and documents reviewed, LPA discovered that the medication antibiotic was only filled one time and sent to the facility but was not administered as described by the prescription. The blister pack was full indicating that the medication was not given. This poses an immediate health and safety risk to resident in care.
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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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2