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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601137
Report Date: 02/22/2024
Date Signed: 02/22/2024 06:02:28 PM

Document Has Been Signed on 02/22/2024 06:02 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: 6DATE:
02/22/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Rick Aban, Aljolyn Maquiddang & Susie HerreraTIME COMPLETED:
12:45 PM
NARRATIVE
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On 2/22/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management visit. LPA met with Caregivers Aljolyn Maquiddang & Susie Herrera then Administrator Rick Aban followed after. LPA explained the purpose of the visit.

LPA toured the facility, and it was observed there is not enough food supply when the current census is six. There is not enough canned food and non-perishable foods.

LPA also observed that a new resident (R1) doesn't have a the required paperwork. It was however produced when LPA asked for documentation. LPA interviewed a staff (S1) and it was mentioned that they are not aware about the health issues that R1 has. They were just informed that the facility will have a move in.

LPA checked the Medication Administration Records (MAR) for R1 and there was documentation.

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.

This report was reviewed with and a copy of the report and appeal rights was 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
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 02/22/2024 06:02 PM - It Cannot Be Edited


Created By: Grace Donato On 02/22/2024 at 02:11 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: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2024
Section Cited
CCR
87405(d)(1)

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87405 Administrator - Qualifications and Duties (d)The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(1) Knowledge of the requirements for providing care and supervision appropriate to the residents.
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Licensee shall submit a plan on how it will address dissimenating information regarding residents to caregivers. Licensee to submit plan by POC deadline.
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This requirement is not met as evidenced by: Based on records review, R1 moved in and caregivers were not given any information regarding the resident, 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
CCR87465(a)(6)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(6)When requested by the prescribing physician or the Department, a record of dosages ...
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Licensee to submit a plan to address documentation regarding MAR. Licensee to submit plan by POC deadline.
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This requirement is not met as evidenced by:
Based on records review, R1 does not have a Medication Administration Records (MAR) log, 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/22/2024 06:02 PM - It Cannot Be Edited


Created By: Grace Donato On 02/22/2024 at 02:34 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: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2024
Section Cited
CCR
87555(b)(26)

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87555 General Food Service Requirements (b) The following food service requirements shall apply: (26)S upplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
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Licensee to submit a plan to address the food supply in the facility. Licensee to submit photos of food supply. LIcensee to submit by POC deadline.
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This requirement is not met as evidenced by: Based on observation, there was not enough supply of canned good and 7-day non-perishable foods, 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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