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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601137
Report Date: 11/06/2023
Date Signed: 11/06/2023 06:36:35 PM

Document Has Been Signed on 11/06/2023 06:36 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:TILMA, SUSANFACILITY TYPE:
740
ADDRESS:735 MONTE ROSA DRIVETELEPHONE:
(650) 492-9429
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY: 6CENSUS: 5DATE:
11/06/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:59 AM
MET WITH:Susie HerreraTIME COMPLETED:
01:30 PM
NARRATIVE
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On 11/06/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit for case management visit for health checks. LPA met with Caregiver Susie Herrera. LPA explained the purpose of the visit.

During the visit LPA observed the residents being prepped for lunch. Masking is required again in the facility. LPA also observed that there is only one caregiver on the premises. LPA reviewed three random resident files.

LPA recommended the following:
- have 2 caregivers scheduled every time, if there is a call out, make sure shift is covered.
Upon review of resident file, LPA noticed that there was a change of condition for a resident (R1). A doctors report was noted saying that R1 had a rash. This change of condition wasn't reported to Licensing.

Deficiency is being cited today as the facility did not ensure that residents R1s change in condition was reported to Licensing. Based on records review, R1 has rash and is still being monitored by the doctor. Facility is being cited for not following reporting requirements.

Deficiencies are cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed and a copy of this report and the Appeal Rights are provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2023
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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Document Has Been Signed on 11/06/2023 06:36 PM - It Cannot Be Edited


Created By: Grace Donato On 11/06/2023 at 11:47 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: 11/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2023
Section Cited
CCR
87211(a)(1)(D)

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87211(a) Each licensee shall furnish... such reports... including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency...(D)Any incident which threatens the welfare...or unexplained absence of any resident. This requirement is not met as evidenced by:
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Licensee to submit a plan in order to address reporting requirements to CCLD. Licensee to submit plan by POC due date.
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Based on record reviews licensee did not comply with the section cited above due an incident where there is a change in condition of R1 not reported to CCLD which poses a potential health, safety or 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.
SUPERVISOR'S NAME:April Cowan
LICENSING EVALUATOR NAME:Grace Donato
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023


LIC809 (FAS) - (06/04)
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