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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601052
Report Date: 05/19/2023
Date Signed: 05/19/2023 01:03:11 PM

Document Has Been Signed on 05/19/2023 01:03 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
SF COASTAL AC/SC, 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: 34DATE:
05/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Resident Care Coordinator, Shayla BrewsterTIME COMPLETED:
10:50 AM
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On May 19, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow on incidents reports submitted to CCL. LPA Charitra met with Resident Care Coordinator, Shayla Brewster and explained the purpose of the visit.

The Licensee reported on May 14, 2023, Resident 1 (R1) had 4 incidents (9:00AM, 9:30AM, 10:00AM, 1:00PM). According to the Licensee, at 9AM, the Med-tech, K.Calip witnessed R1 walk up to R2, throw his/her water in R2's face and then grab R2 by the shirt. At 9:30AM, K.Calip witnessed R1 slap R3 in the face and hit his/her arm. At 10:00AM, med-tech observed R1 hit R4 in the chest and spit water all over R4's head. At 1:00PM, med-tech witnessed R1 grab a hot cup of soup and throw it on R5 and R5's family

The Licensee reported on May 15, 2023, R1 had another incident. According to the Licensee, Med-tech observed R1 hitting and punching R6. R6 was observed with scratches on his/her arm.

The Licensee indicated that after each of R1's incidents, R1 was redirected and R1 was placed on frequent checks. PCP and R1's responsible party was notified.

During the visit, LPA reviewed R1's file and interviewed the Resident Care Coordinator. Based on R1's file reviewed, R1 has a diagnosis of Dementia and was not diagnosed with any aggressive or inappropriate behaviors. In addition, facility was unable to provide any reassessments for R1 after his/her incidents and failed to provide any documentation indicating that R1 was checked on every 30 minutes according to Med-Tech and Resident Care Coordinator.

Continue to 809C
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SILVER OAKS
FACILITY NUMBER: 415601052
VISIT DATE: 05/19/2023
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According to the Resident Care Coordinator, R1 has not had a prior history of aggression and is currently at the hospital for 5150. Facility spoke to R1's responsible party and indicated that R1 requires a one on one caregiver. In addition, the Resident Care Coordinator indicated that a reassessment will be conducted when R1 returns back to the community. Furthermore, the Resident Care Coordinator indicated that a Care meeting is to be scheduled and conducted.

Based on the information collected and file reviewed, the facility failed to reassess R1 after R1 had 5 incidents showing aggressive behaviors towards others which were not identified in his/her file. In addition, the facility failed to develop an individualized needs and service plan for R1 to address R1's aggressive behaviors.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with Resident Care Coordinator; a copy of the report is provided with appeal rights.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/19/2023 01:03 PM - It Cannot Be Edited


Created By: Komal Charitra On 05/19/2023 at 10:22 AM
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: 05/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2023
Section Cited
CCR
87463(a)

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87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to...
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Licensee/Administrator to develop a plan on how facility will address R1's aggressive behaviors and how facility will provide care to R1 knowing R1 has aggressive behaviors.
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Based on information collected and file reviewed, the facility failed to reassess R1 after having 5 incidents of aggressive behaviors which was not identified in his/her file.
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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.
SUPERVISOR'S NAME:Cara Smith
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023


LIC809 (FAS) - (06/04)
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