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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601052
Report Date: 07/31/2023
Date Signed: 07/31/2023 01:42:38 PM


Document Has Been Signed on 07/31/2023 01:42 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: 36DATE:
07/31/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Shayla BrewsterTIME COMPLETED:
01:45 PM
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
On this day Licensing Program Analyst (LPA) Jaime Vado and John Calandra conducted an unannounced case management incident investigation visit responding to an incident that occurred on 07/25/2023. LPAs met with resident care coordinator (RCC) Shayla Brewster and explained the purpose of today's visit. The administrator Ollie Vance is not present due to conducting a resident assessment on this day.

During the visit LPAs interviewed med-tech on duty and the RCC. According to the RCC the discovery of the missing medications was found on the morning of 07/25/2023 while conducting a narcotics medication count during a shift change RCC and another med-tech discovered the missing narcotics. Per RCC upon discovery of the missing narcotic she notified the administrator, Ollie Vance, who then came in to assist in locating the missing narcotic and assist in counting the narcotics to ensure an error was not made. As a result they were not able to locate the missing narcotic. Video camera footage was reviewed by RCC and the administrator and was able to identify S1 as the main suspect. The administrator then notified Menlo Park Police Department to report the incident. The police department investigated and made contact with S1 on 07/26/2023. It was confirmed that he/she had the missing narcotics per admission by S1. The missing narcotics were not returned to the facility. It was discovered that the taken narcotics were from two different residents and both residents received the narcotic as a pro re nata (PRN) while on hospice care. Neither resident missed a dose. RCC notified family members of the residents and the residents' hospice agencies. The narcotics were refilled as a result. No further missing narcotics were discovered after a subsequent audit. S1 was terminated as a result. Facility is awaiting the final police report from the police department.

No citations issued. Report is reviewed with RCC Shayla Brewster.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023
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 1