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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601052
Report Date: 04/28/2023
Date Signed: 08/18/2023 12:15:43 PM


Document Has Been Signed on 08/18/2023 12:15 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: 33DATE:
04/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Shayla BrewsterTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Grace Donato and Licensing Program Manager (LPM) Jackie Jin conducted an unannounced case management visit regarding an elopement from 04/18/2023. LPA and LPM met with Resident Care Coordinator, Shayla Brewster. Adminstrator, Ollie Vance arrived shortly.

It was reported that resident (R1) eloped and was found just outside the facility after 10 minutes. A family member entered in the code to exit the facility. The door wasn't shut properly so the resident was able to go outside.

After the incident the facility updated the policy, which was implemented on 4/21/23. Staff were advised that codes are only for staff members and management. The family members were also advised that the codes will be updated and would not be given to them for security and safety purposes both for the residents and the facility. A camera was also installed to monitor who punches in the codes on the exit door. In-service training was conducted on 04/17/2023 with staff regarding updated policy on giving out codes to the doors to family.

No deficiency cited during today's visit.

This report was reviewed with Ollie Vance and copy has been provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
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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