415601052-5-12-2023-14-AS-CSMH-CSBU8A-20230530152111

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601052
Report Date: 05/12/2023
Date Signed: 05/12/2023 10:59:14 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
04/10/2023 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230410114637

FACILITY NAME:	SILVER OAKS		FACILITY NUMBER:	415601052
ADMINISTRATOR:	OLLIE VANCE		FACILITY TYPE:	740
ADDRESS:	16 COLEMAN PLACE		TELEPHONE:	(650) 322-2022
CITY:	MENLO PARK	STATE: CA	ZIP CODE:	94025
CAPACITY:	43	CENSUS: 34	DATE:	05/12/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator, Ollie Vance		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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-Staff failed to prevent residents from being harmed by another resident
-Staff failed to provide a safe and comfortable environment
-Facility is short staffed
-Staff failed to safeguard residents' personal belongings

INVESTIGATION FINDINGS:

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On May 12, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Ollie Vance and explained the purpose of the visit.

Regarding the allegation that staff failed to prevent residents from being harmed by another resident, and staff failed to provide a safe and comfortable environment, there is no additional information forthcoming. However, during the initial reporting, the reporting party indicated the Resident 1 (R1) who has dementia, walks around the facility, hitting and grabbing other residents in care causing other residents to not feel safe.

As part of the investigation, LPA interviewed the facility administrator, staff, and family members.

According to the administrator, she denied this allegation and acknowledged that R1 has severe dementia and has behaviors where he/she does grab and touch residents or staff, however Administrator has never witnessed R1 harming another resident. In addition the administrator and 4/4 of the staff interviewed indicated that touching and/or grabbing is a common behavior dementia residents have. Furthermore, the Administrator, 4/4 staff members and 4/4 family members indicated that if they observe a resident grabbing, touching, or starting an altercation with another resident, staff immediately intervene, redirect the resident, assess for injuries, and notify all required parties. (CONT. to 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20230410114637

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/12/2023

NARRATIVE

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During the visits conducted at the facility (4/17/2023 and 5/12/23) LPA observed R1 to be sitting near the Resident Care Coordinator's office or walking back and forth from his/her room to the communal living room area.

Regarding the allegation that facility is short staffed, according to the reporting party, the facility is short staffed.

During the investigation, LPA interviewed administrator, staff, and family members. According to the administrator, she denied this allegation and indicated she is fully staffed at the facility. In addition, 4/4 of the staff members and 4/4 family members interviewed indicated that they have not experienced any staffing concerns at the facility.

Regarding the allegation that staff failed to safeguard residents' personal belongings, according to the reporting party, R1 picks up stuff from other residents' rooms.

During the investigation, LPA interviewed the administrator, staff, and family members. The administrator denied this allegation and indicated that because this is a memory care facility, residents have wandering behaviors and will grab things, however if facility staff do witness a resident wandering into another resident's room and picking up their personal belongings, staff will immediately take it and return it. According to 4/4 of the staff members interviewed, they indicated that resident's personal belongings are labeled and if they find an item misplaced or something a resident has but does not belong to them, staff will take it and return it to the owner. In addition, according to 4/4 of the family members interviewed, they have observed residents wander into other resident's rooms and grab something that isn't theirs, however they understand that it is a part of the behaviors a dementia resident has.

Therefore, based on the observations conducted during the visit, the above allegations are UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Report is reviewed with Administrator and a copy is provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
04/10/2023 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230410114637

FACILITY NAME:	SILVER OAKS		FACILITY NUMBER:	415601052
ADMINISTRATOR:	OLLIE VANCE		FACILITY TYPE:	740
ADDRESS:	16 COLEMAN PLACE		TELEPHONE:	(650) 322-2022
CITY:	MENLO PARK	STATE: CA	ZIP CODE:	94025
CAPACITY:	43	CENSUS:	DATE:	05/12/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator, Ollie Vance		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Resident sustained an injury while in care

INVESTIGATION FINDINGS:

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On May 12, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Administrator, Ollie Vance and explained the purpose of the visit.

Regarding the allegation resident sustained an injury while in care, there is no additional information forthcoming from the reporting party, however during the initial reporting, the reporting party stated that a resident (name unknown) sustained a bruise while in care and suspects it to be cause by Resident 1 (R1).

As part of the investigation, LPA interviewed facility administrator, staff and family members.

The administrator denied this allegation and stated that she has never witnessed R1 harm another resident. In addition, 4/4 staff members acknowledged that R1 grabs and touches other residents, however they have not observed R1 physically harming another resident in care. Furthermore, during the visits conducted at the facility (4/17/2023 and 5/12/23) LPA observed R1 to be sitting near the Resident Care Coordinator's office or walking back and forth from his/her room to the communal living room area.

Based on the above interviews conducted, this allegation is UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis.

Report is reviewed with Administrator and a copy is provided

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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