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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601052
Report Date: 04/18/2024
Date Signed: 04/18/2024 04:54:31 PM


Document Has Been Signed on 04/18/2024 04:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



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
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Joshua Lambengco & Bernadette KangTIME COMPLETED:
04:00 PM
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On 4/18/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management incident visit.. LPA met with Executive Director, Joshua Lambengco and Resident Care Coordinator, Bernadette Kang and explained the purpose of today's visit.

On 2/12/2024, Licensing received a report of resident (R1) who died due to choking. LPA investigated and interviewed staff. Staff member (S1) mentioned that R1 was having snacks during that time and was seated on the bed while being fed. R1 was fine eating until R1 stopped talking. R1 then signaled pointing to his/her throat. S1 immediately called for help and emergency services were called. Police and 911 arrived and took over.

Based on record reviews, R1 is non ambulatory, no assistance with meal reminders or feeding support. R1 also has a Physician Orders for Life-Sustaining Treatment (POLST) order of Do Not Resuscitate. Staff has updated training for first Aid. A police report was obtained and stated that emergency services were instructing the staff to take out food items from R1s mouth.

No deficiencies being cited today. Report is reviewed and copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
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.

LIC809 (FAS) - (06/04)
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