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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601052
Report Date: 03/22/2022
Date Signed: 04/05/2022 04:06:11 PM

Document Has Been Signed on 04/05/2022 04:06 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SILVER OAKSFACILITY NUMBER:
415601052
ADMINISTRATOR:RUBIO, NANCYFACILITY TYPE:
740
ADDRESS:16 COLEMAN PLACETELEPHONE:
(707) 592-1157
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY: 43CENSUS: 38DATE:
03/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nancy RubioTIME COMPLETED:
09:45 AM
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
During complaint investigation, deficiency of the CA Code of REgulations, Title 22 was observed to have occurred and is cited on a following page.

Based on interviews with staff and a review of medical records from Sutter Health/Palo Alto Medical Foundation (PAMF), facility staff failed to seek medical attention in a timely manner for client #1, who was eventually diagnosed with a UTI. On 3/13/20, staff observed yellowish vaginal discharge and blood in client's diaper, but did not seek medical intervention nor report to MD until 3/20/2020, 7 days later. MD prescribed topical external treatment based on symptoms described. On 4/2/20, staff reported to MD that client has dark urine and is very confused. After results from urinalysis testing, UTI was confirmed on 4/3/20 and client was treated with a lengthy course of antibiotics. The observations, communication and treatment were not documented in facility notes due to staff shortage.





--------------------This report is delivered via phone and emailed to administrator for signature------------
-------------------Signed 2 page report to be returned to CCLD via email or fax to 650/266-8841-----------------
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/05/2022 04:06 PM - It Cannot Be Edited


Created By: Audrey Jeung On 03/14/2022 at 07:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SILVER OAKS
FACILITY NUMBER: 415601052

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2022
Section Cited

1
2
3
4
5
6
7
RESIDENT RECORDS
Each resident's record shall contain at least a continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services.
This requirement was not met, as administrator confirmed that staff failed to
8
9
10
11
12
13
14
document staff observations, communication and treatment for client #1 when staff observed client with unusual vaginal discharge in March 2020. Licensee failed to document client's condition and staff response, which posed a potential health, safety or personal rights risk to clients.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Julio Montes
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2