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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601052
Report Date: 04/18/2024
Date Signed: 04/18/2024 04:49:19 PM

Unfounded


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
04/08/2024 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240408142422
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:
11:30 AM
MET WITH:Joshua Lambengco & Bernadette KangTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff are not mandated reporter certified
INVESTIGATION FINDINGS:
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On 4/18/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director, Joshua Lambengco and Resident Care Coordinator, Bernadette Kang and explained the purpose of today's visit.

Regarding the allegation of Staff are not mandated reporter certified, Responsible party (RP) stated that a full-time staff doesn’t have mandated reporter training. RP stated that the staff is not reporting things (residents that smell, hitting each other, coughing or thirsty) that happen around the facility to licensing. RP stated that the staff does tell other staff about what he/she sees but that is it.

LPA interviewed Resident Care Coordinator (RCC) Bernadette Kang and she mentioned that everyone needs to sign the SOC341A (Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders) for Mandatory Reporting upon hiring. LPA interviewed four staff members and it was mentioned that when an incident happens a staff reports it to the Med Tech (MT). MT in turn assess the resident and calls 911 for further evaluation. MT also calls the Responsible Parties and Primary Care Physician. In cases where MT is not available, RCC and Executive Director/Administrator is called. Incident report is then created and submitted to Licensing.
Unfounded
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 14-AS-20240408142422
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
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Based on records review, four staff records were checked and all SOC341A Mandatory Reporting forms were signed.

Therefore, based on the interviews conducted, files reviewed, and information collected, the allegation mentioned is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

The report was reviewed, and a 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
LIC9099 (FAS) - (06/04)
Page: 2 of 2