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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601137
Report Date: 02/22/2024
Date Signed: 02/22/2024 06:09:49 PM

Unsubstantiated


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
11/29/2022 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20221129135944
FACILITY NAME:SANDHILL ASSISTED LIVING LLCFACILITY NUMBER:
415601137
ADMINISTRATOR:TILMA, SUSANFACILITY TYPE:
740
ADDRESS:735 MONTE ROSA DRIVETELEPHONE:
(650) 492-9429
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:6CENSUS: 6DATE:
02/22/2024
UNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Rick Aban, Aljolyn Maquiddang & Susie HerreraTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff do not ensure that the facility has a working telephone at all times
Staff are preventing resident from receiving hospice services because they do not answer the facility door
INVESTIGATION FINDINGS:
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On 2/22/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegations. LPA met with Caregivers Aljolyn Maquiddang & Susie Herrera then Administrator Rick Aban followed after. LPA explained the purpose of the visit.

Regarding the allegations of staff does not ensure that the facility has a working telephone at all times and staff are preventing resident from receiving hospice services because they do not answer the facility door, reporting party (RP) stated that the hospice agency attempted to call the facility, but staff did not answer the telephone. Hospice staff attempted to visit the resident, but staff did not answer the door. Hospice staff continued to call and attempt to visit but were unable to gain access to the resident (R1) until 11/29/2022.

LPA Jeung was able to interview three staff members, S1 stated that staff do not want to answer the phone because they don't know what to say and they're shy. Instead of answering the phone, they will give the phone to senior caregivers. Another staff member, S2 advised that it works all the time, and that they answer it when it rings. S2 also stated that there was power outage the week before 12/07/2022 between 8pm until 2am. However it was not mentioned what the exact day was. S3 did not mention anything regarding telephone calls.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
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 5
Control Number 14-AS-20221129135944
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: SANDHILL ASSISTED LIVING LLC
FACILITY NUMBER: 415601137
VISIT DATE: 02/22/2024
NARRATIVE
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Based on records review, a hospice visit log was provided, and it indicated that the visit’s happened on 11/25/2022, 11/29/2022, 11/30/2022. There was also a report that hospice was supposed to be at the facility on 11/27/2022 with an arrival time of 9pm. On this report it was noted that the power outage happened from 11:30pm to 2am.

Based on interviews, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No citations for today. Report is reviewed and copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
11/29/2022 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20221129135944

FACILITY NAME:SANDHILL ASSISTED LIVING LLCFACILITY NUMBER:
415601137
ADMINISTRATOR:TILMA, SUSANFACILITY TYPE:
740
ADDRESS:735 MONTE ROSA DRIVETELEPHONE:
(650) 492-9429
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:6CENSUS: 6DATE:
02/22/2024
UNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Rick Aban, Aljolyn Maquiddang & Susie HerreraTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Staff mismanaged resident's medication
Staff are not competent to meet client's needs
INVESTIGATION FINDINGS:
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On 2/22/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegations. LPA met with Caregivers Aljolyn Maquiddang & Susie Herrera then Administrator Rick Aban followed after. LPA explained the purpose of the visit.

Regarding the allegation of staff mismanaged resident's medication, RP stated that when the doctor (D1) inquired with staff about medications given, they were told that R1 had taken Lasik’s, two Tylenol (500 mg each) and Lorazepam. The RP notes the Lorazepam is prescribed "as needed" for anxiety. When the doctor and nurse reviewed the resident's medication record is was documented that the resident is given Lorazepam daily by staff.

Based on records review, in the residents medication list Lasix, Tylenol and Lorazepam are all as needed medications or PRN. In the Medication Administration Record (MAR) for November 2022, Lasix was given for seven days, from 11/2/22 to11/8/22 until it was discontinued on 11/9/22. Tylenol was given twice everyday. There was no log of Lorazepam for this month. It is also noted in MAR that Lasix and Tylenol are not noted as PRN medication. There were also no records or documentation regarding a request to give the PRN medication to R1.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 14-AS-20221129135944
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: SANDHILL ASSISTED LIVING LLC
FACILITY NUMBER: 415601137
VISIT DATE: 02/22/2024
NARRATIVE
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Regarding the allegation of staff are not competent to meet client's needs, RP stated that R1s abdomen was descended and staff was unable to tell the RP when the resident's last bowel movement was.

S1 stated that there were no logs or documentation regarding the resident’s bowel movement. Unless they remember when it was.

Therefore, based on the interviews conducted and information collected, the above allegations are
determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22
cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20221129135944
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: SANDHILL ASSISTED LIVING LLC
FACILITY NUMBER: 415601137
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2024
Section Cited
CCR
87465(d)(2)
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87465 Incidental Medical and Dental Care
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication...(2) The date and time of each contact with the physician, and the physician's directions...
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Licensee to submit a plan to address documentation of PRN medications to residents. Licensee to submit plan by POC deadline.
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This requirement is not met as evidenced by: Based on records review, two medications, Lasix & Tylenol, were given to R1 with no proper documentation that it was requested from the doctor, which poses an immediate health, safety, and personal rights risk to persons in care.
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Type A
02/23/2024
Section Cited
CCR
87411(c)
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87411 Personnel Requirements - General(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
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Licensee to submit a plan to address documentation of activities of daily living. Licensee to submit plan by POC deadline.
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This requirement is not met as evidenced by: Based on interview, S1 stated that there were no logs for activities of daily living, which poses an immediate health, safety, and personal rights risk to persons in care.
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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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5