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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601052
Report Date: 03/18/2025
Date Signed: 03/18/2025 11:41:19 AM

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
12/26/2024 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20241226105243
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: 43DATE:
03/18/2025
ANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Joshua LambengcoTIME COMPLETED:
11:53 AM
ALLEGATION(S):
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Staff are mismanaging resident's medication
INVESTIGATION FINDINGS:
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On March 18, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Joshua Lambengco explained the purpose of the visit.

Regarding the allegation, staff are mismanaging resident's medication, according to the reporting party, it was observed that there were pills under Resident 1's (R1's) bed that was either not swallowed or was spit out. In addition, photos were provided by reporting party.

During the investigation, LPA interviewed the administrator, staff and reviewed photos that were provided. Based on the photo provided, LPA did observe medication on the floor in R1's room. According to the administrator, R1 is no longer a resident at the facility. LPA was unable to count R1's medication or interview R1 during the complaint visit. According to the administrator and staff interviewed, R1 has a behavior where he/she will hide the medication in his/her mouth while staff are present and spit it out when staff leave. Facility failed to ensure R1 did take his/her medications as prescribed by the doctor, knowing R1 has a behavior of spitting and/or hiding their medication. (continue to 9099C)




Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
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 6
Control Number 14-AS-20241226105243
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: 03/18/2025
NARRATIVE
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Based on the information collected, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Administrator and a copy is provided with appeal rights.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
12/26/2024 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20241226105243

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: DATE:
03/18/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Joshua LambengcoTIME COMPLETED:
11:53 AM
ALLEGATION(S):
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Resident sustained injuries due to staff neglect
Staff are not properly cleaning resident's room
Staff are not ensuring resident has clean bedding
Staff are not meeting resident's hygiene needs
Staff are not ensuring resident's room is free of mold
Staff are not ensuring resident has proper bedding
INVESTIGATION FINDINGS:
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On March 18, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Joshua Lambengco explained the purpose of the visit.

Regarding the allegations, resident sustained injuries due to staff neglect, according to the reporting party, it was noted that Resident 1 (R1) rubbed toothpaste on his/her feet instead of lotion which caused his/her feet skin to peel due to the burns.

During the invesitgation, LPA interviewed the administrator and interviewed staff and reviewed R1's care plan. According to the administrator, he denied this allegation, and indicated that R1 is an independent resident. LPA was unable to interview R1 as he/she is no longer a resident at the facility. The administrator indicated, R1's family brings toothpaste to him/her without notifying staff and due to R1's behaviors, he/she will hide it. (continue to 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 14-AS-20241226105243
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: 03/18/2025
NARRATIVE
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Regarding the allegation, staff are not properly cleaning resident's room, according to the reporting party, there are dishes and cups stacked on top of each other all over R1's room and stated that the flies are flying around because the food is old and been sitting for a while.

During the complaint visit, LPA observed 10 random sample of resident's rooms including R1's room and observed all rooms to be clean, pest-free, and with no dishes/cups.

Regarding the allegation, staff are not ensuring resident has clean bedding, according to the reporting party, it was observed that R1's bed was covered in dried feces which means that it has been there for several days and R1's room was not being checked on.

During the complaint visit, LPA observed a random sample of 10 resident rooms, including R1's room and observed all resident bedding to be clean and odor-free. LPA did not observe any fecal matter on R1's bedding.

Regarding the allegation, staff are not meeting resident's hygiene needs, according to the reporting party, R1 did not have toothpaste in the bathroom and R1's hair was greasy.

During the investigation, LPA observed toothpaste to be locked in the storage room. According to staff interviewed, the toothpaste is locked due do cautionary purposes because all the residents at the facility have dementia. The staff bring toothpaste from the storage room when they are assisting residents brush their teeth. According to R1's service plan, R1 is independent and staff help with assisting with showers every week and brushing R1's teeth morning and night.

Regarding the allegation, staff are not ensure resident's room is free of mold, according to the reporting party, it was observed that there was mold in R1's room and bathroom.

During the investigation, LPA toured and observed a random sample of 10 resident's rooms including R1's bedroom and bathroom. LPA did not observe any mold in the rooms.

(continue to 9099C)
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 14-AS-20241226105243
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: 03/18/2025
NARRATIVE
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Regarding the allegation, staff are not ensuring resident has proper bedding, according to the reporting party, it was observed R1 only had a fitted sheet and a comforter, however there was no flat sheet on the bed.

During the visit, LPA interviewed the administrator and staff, and toured a random sample of 10 rooms, including R1's room. During the visit, LPA observed all 10 rooms to have a fitted sheet, a comforter and a flat sheet. According to the administrator and staff interviewed, the family provides bed linens for the residents, however if residents don't have any, the facility does provide them. During the visit, LPA did observed extra linen present.

Therefore, based on interviews conducted, record review and observations, the department has determined that although the above allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED.

Report is reviewed with the administrator and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 14-AS-20241226105243
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: 03/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/19/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical...care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
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Licensee/administrator shall provide in-service training regarding medication management.
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Based on interviewed conducted, administrator and staff interviewed, R1 has a behavior where he/she will hide the medication in his/her mouth while staff are present and spit it out when staff leave. Facility failed to ensure R1 did take his/her medications as prescribed by the doctor, knowing R1 has a behavior of spitting and/or hiding their medication which poses an immediate health and safety risk to residents 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: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6