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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601137
Report Date: 08/01/2024
Date Signed: 08/01/2024 02:50:07 PM

Document Has Been Signed on 08/01/2024 02:50 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SANDHILL ASSISTED LIVING LLCFACILITY NUMBER:
415601137
ADMINISTRATOR/
DIRECTOR:		TILMA, SUSANFACILITY TYPE:
740
ADDRESS:735 MONTE ROSA DRIVETELEPHONE:
(650) 492-9429
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY: 6CENSUS: 5DATE:
08/01/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Ricardo Aban, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On August 1, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 8:30 am to complete the Annual 1-year required inspection started on July 25, 2024. LPA Calandra was greeted by Ricardo Aban, Administrator and explained the purpose of the visit.

LPA Calandra toured the physical plant. This is a 1-story building with 6 bedrooms, two bathrooms, a staff bedroom and staff bathroom, garage, dining room, living room, kitchen, front and back yards. The facility was maintained at a comfortable temperature of 71 degrees Fahrenheit. No accessible bodies of water or hazards were observed. Hot water temperature was measured within the required range of 105-120 degrees Fahrenheit. The facility's fire extinguishers were last checked on June 1, 2024 and were observed to be fully charged. No food was observed to be expired except for one item which was discarded in the presence of the LPA. The facility had the required 7 days of non perishables and 2 days of perishables on site. The facility's smoke detectors and carbon monoxide detector were observed to be in working order. The facility's first aid kit had the required tweezers, bandages, scissors, thermometer, and guide.

A Technical violation was provided for not ensuring that all food is stored in covered containers.

A Technical violation was provided for not recording each hospice led training session.

A Type B violation was provided for not having screened fireplaces.

A Type B violation was also provided for not notifying licensing that exterior gates are locked.

Deficiencies are cited under California Code of Regulations, Title 22, cited on the LIC 809-D. Failure to correct the deficiencies may result in civil penalties.

An exit interview was conducted. This report was reviewed with Ricardo Aban, Administrator and a copy of the report along with Appeal rights left at the facility.




SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
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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Document Has Been Signed on 08/01/2024 02:50 PM - It Cannot Be Edited


Created By: John Calandra On 08/01/2024 at 02:09 PM
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: SANDHILL ASSISTED LIVING LLC
FACILITY NUMBER: 415601137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(7)
Personal Accommodations and Services
(7) Fireplaces and open-faced heaters shall be adequately screened.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 fire places which did not have screens, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
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Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
Type B
Section Cited
CCR
87705(l)(1)
Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (1) Licensees shall notify the licensing agency of their intention to lock exterior doors and/or perimeter fence gates.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview of the administrator, the licensee did not comply with the section cited above in 2 out of 2 fences which were observed to have locks on them and are locked according to the administrator, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
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Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2024


LIC809 (FAS) - (06/04)
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