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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415601137
Report Date:
07/24/2023
Date Signed:
07/24/2023 03:51:25 PM
Document Has Been Signed on
07/24/2023 03:51 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:
SANDHILL ASSISTED LIVING LLC
FACILITY NUMBER:
415601137
ADMINISTRATOR:
TILMA, SUSAN
FACILITY TYPE:
740
ADDRESS:
735 MONTE ROSA DRIVE
TELEPHONE:
(650) 492-9429
CITY:
MENLO PARK
STATE:
CA
ZIP CODE:
94025
CAPACITY:
6
CENSUS:
3
DATE:
07/24/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
Susie Herrera
TIME COMPLETED:
04:15 PM
NARRATIVE
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LPA Grace Donato conducted an unannounced annual visit to the facility. LPA met with caregiver Susie Herrera.
LPA toured the facility inside and outside with the caregiver. While touring the facility it was observed that the room temperature was at 78 deg F. Hot water was also tested and temperature was 110 deg F. Each resident rooms were checked. The residents have adequate amount of linens and incontinence care items. Adequate lighting is available in all rooms. All personal belongings are intact. All residents are comfortable and taken care of. Carbon monoxide monitor is working properly. All fire extinguishers have been checked. Bathrooms were observed to be in good repair equipped with non-skid mats and grab bars. There is also adequate amount of food. 2 days for perishables and & 7 days non-perishable.
Medication review was done for all residents and all medications are accounted for and centrally stored medication records are updated.
3 staff records available in the facility were reviewed . All staff records reviewed has criminal record clearance and are associated with the facility. Based on record reviews, it was noted that 2 the facility staff does not have updated CPR & First Aid training. Personnel records are not maintained in the facility resulting for some documents being unavailable when needed.
Resident records were checked. 2 out 3 doesn’t have signature of Licensee/Administrator in the admission agreement. One resident doesn’t have signature on LIC 603 (Needs & Appraisals), another resident doesn’t have signature on LIC 621 (Personal Property & Valuables). Licensee/Administrator was advised to have these records signed. All records that still have the Orchid Lan name should be updated to Sandhill Assisted Living.
SUPERVISOR'S NAME:
Jackie Jin
TELEPHONE:
(714) 319-3786
LICENSING EVALUATOR NAME:
Grace Donato
TELEPHONE:
(714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE:
07/24/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/24/2023
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
7
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:
07/24/2023
NARRATIVE
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Staff are scheduled either up until 7 pm or 10 pm. Administrator confirmed on phone that live-in staff take care of residents needing assistance after shift and is compensated for work done during that time.
Facility doesn't have a record of Emergency Disaster drill log. LPA advised administrator that drill shall be completed quarterly.
LPA requested licensee to submit the following and was received by 7/24/2023:
LIC 308 Designation of Facility Responsibility
LIC 500 Personnel Report
Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties.
Report is reviewed with caregiver and a copy is provided with appeal rights.
SUPERVISOR'S NAME:
Jackie Jin
TELEPHONE:
(714) 319-3786
LICENSING EVALUATOR NAME:
Grace Donato
TELEPHONE:
(714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE:
07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/24/2023
LIC809
(FAS) - (06/04)
Page:
2
of
7
Document Has Been Signed on
07/24/2023 03:51 PM
- It Cannot Be Edited
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on 2 Personnel Files are not on file in the facility and is not readily available for checking which poses an immediate health and safety risk to residents..
POC Due Date:
07/25/2023
Plan of Correction
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2
3
4
Submit plan of action to ensure that files are readily to available for checking. Make the files available in the facility.
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:
Jackie Jin
TELEPHONE:
(714) 319-3786
LICENSING EVALUATOR NAME:
Grace Donato
TELEPHONE:
(714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE:
07/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/24/2023
LIC809
(FAS) - (06/04)
Page:
3
of
7
Document Has Been Signed on
07/24/2023 03:51 PM
- It Cannot Be Edited
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above because 2 staff members doesn't have valid CPR training which poses an immediate health and safety risk to residents or personal rights risk to persons in care.
POC Due Date:
07/25/2023
Plan of Correction
1
2
3
4
Submit a plan on how the 2 staff members will get the training required.
Type A
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review 2 personnel records were not readily available in the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
07/25/2023
Plan of Correction
1
2
3
4
Submit a plan on how to make staff records readily available in the facility.
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:
Jackie Jin
TELEPHONE:
(714) 319-3786
LICENSING EVALUATOR NAME:
Grace Donato
TELEPHONE:
(714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE:
07/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/24/2023
LIC809
(FAS) - (06/04)
Page:
4
of
7
Document Has Been Signed on
07/24/2023 03:51 PM
- It Cannot Be Edited
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review 2 personnel records were not readily available in the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
07/25/2023
Plan of Correction
1
2
3
4
Submit plan of action to ensure that files are readily to available for checking. Make the files available in the facility.
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based interview no emergency drill logs are available in the facility. Drills in the facility were done every 6 months instead of quarterly which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
07/25/2023
Plan of Correction
1
2
3
4
Submit a plan on action on when this drills are going to be scheduled and ensure that staff sign for the in service training.
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:
Jackie Jin
TELEPHONE:
(714) 319-3786
LICENSING EVALUATOR NAME:
Grace Donato
TELEPHONE:
(714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE:
07/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/24/2023
LIC809
(FAS) - (06/04)
Page:
5
of
7
Document Has Been Signed on
07/24/2023 03:51 PM
- It Cannot Be Edited
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above due to 2 out 3 doesn’t have signature of Licensee/Administrator in the admission agreement. One resident doesn’t have signature on LIC 603 (Needs & Appraisals), another resident doesn’t have signature on LIC 621 (Personal Property & Valuables) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/28/2023
Plan of Correction
1
2
3
4
Have all necessary documents signed by either party.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Jackie Jin
TELEPHONE:
(714) 319-3786
LICENSING EVALUATOR NAME:
Grace Donato
TELEPHONE:
(714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE:
07/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/24/2023
LIC809
(FAS) - (06/04)
Page:
6
of
7
Document Has Been Signed on
07/24/2023 03:51 PM
- It Cannot Be Edited
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
07/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87211(a)(1)(D)
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
This requirement is not met as evidenced by: Based
Deficient Practice Statement
1
2
3
4
Based on interview, a resident mentioned that he/she fell several times. No report was submitted to licnesing. The licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
07/25/2023
Plan of Correction
1
2
3
4
Provide a plan of action as to how to address incident reports.
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:
Jackie Jin
TELEPHONE:
(714) 319-3786
LICENSING EVALUATOR NAME:
Grace Donato
TELEPHONE:
(714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE:
07/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/24/2023
LIC809
(FAS) - (06/04)
Page:
7
of
7