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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601137
Report Date: 08/16/2023
Date Signed: 08/16/2023 11:47:19 AM

Document Has Been Signed on 08/16/2023 11:47 AM - 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: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: 4DATE:
08/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregiver, Susie HerreraTIME COMPLETED:
12:00 PM
NARRATIVE
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On August 16, 2023, Licensing Analyst (LPA) Murial Han conducted an unannounced case management visit to follow up on an incident that was reported by the facility. LPA met with caregiver Susie Herrera and explained the purpose of the visit.

On August 11, 2023, facility reported to CCL that a dog bit a visitor and this happened on August 10, 2023 at 7:15PM. Facility staff immediately removed the dogs and provided first aide care to the family member which revealed no bleeding but bruising were noted on both lower legs.

During today's case management visit, LPA conducted facility tour, interviewed resident, facility staff, and reviewed records.

According to facility staff, the dogs stay in the garage and the garage is connected to the kitchen that is connected to the rest of the facility. To prevent the dogs from entering the kitchen, there is mental gate in front of the garage door and the kitchen and to prevent the dogs from leaving the kitchen and there is a sliding door that should remained closed at all times.

On the day of the incident, staff #1 (S1) was in the kitchen and both dogs managed to get out of the garage and entered the kitchen as the mental gate was not closed all the way. When staff #2 (S2) gently open the kitchen door to show a family member of a call pendant device in the kitchen, both dogs ran out from the kitchen and one of them bit the family member.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: SANDHILL ASSISTED LIVING LLC
FACILITY NUMBER: 415601137
VISIT DATE: 08/16/2023
NARRATIVE
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Facility staff acknowledged that the mental gate should've been closed all the way to prevent these situation from happening.

Deficient is cited under California Health and Safety Code on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed and reviewed with caregiver;

Findings were discussed with administrator over the phone.

A copy of this report and the Appeal Rights is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 08/16/2023 11:47 AM - It Cannot Be Edited


Created By: Murial Han On 08/16/2023 at 11:11 AM
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: 08/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2023
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal Rights of Residents in All Facilities..a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful..
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The administrator/licensee will develop a plan to ensure this does not happen again and the plan shall include what actions that the facility shall take to ensure a comfortable, safe, healthful environment is provided
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The requirement is not met as evidenced by facility dog presented aggression toward a family member and bit the family member which posed an immediately health risk for resident in care.
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environment is provided for resident, family members, visitors, etc.

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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.
SUPERVISOR'S NAME:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023


LIC809 (FAS) - (06/04)
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