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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601137
Report Date: 06/28/2022
Date Signed: 06/28/2022 01:09:26 PM

Document Has Been Signed on 06/28/2022 01:09 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
CCLD Regional Office, 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: DATE:
06/28/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Administrator/Licensee, Susan Somporn TIME COMPLETED:
01:20 PM
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On June 28, 2022 at 10:45AM, Licensing Program Analyst (LPA) Komal Charitra met with Administrator/Licensee Susan Somporn to conduct an announced Pre-Licensing inspection for a change of ownership. LPA Charitra was properly screened for COVID-19 at entry point.

LPA observed the indoor and the outdoor passageways are free of obstruction. The Administrator provided a tour of the facility. This is a single story facility with 7 bedrooms (5 resident rooms and 2 staff room) and 4 bathrooms. There were 3 residents and one staff present during the visit. 3 resident rooms are occupied; all are private. One bedroom was observed to be shared room with beds 6ft apart. All bathrooms were observed to be equipped with grab bars, non-skid mats, hand washing signage, liquid soap, paper towels, and a covered trash can. The facility is observed to be spacious, clean, and odor-free. There was good lighting and the facility was measured at 69 degrees Fahrenheit (F).

The living room and the dining room is observed to be comfortable, spacious with adequate furniture. The activities calendar is posted in the living room. The outdoor space is spacious. Emergency exiting plans are posted.

LPA observed COVID-19 signs through-out the facility and social distancing stickers are posted on the floors. The hot water temperature was measured in the 4 bathrooms, showers and the kitchen were at 105- 110 degrees F. LPA observed toxins, chemicals, disinfectants to be locked and inaccessible to the residents. There are sufficient lighting in the hallways. Night lights are present in hallways and bedrooms.

CONT. to 809C
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2022
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SANDHILL ASSISTED LIVING LLC
FACILITY NUMBER: 415601137
VISIT DATE: 06/28/2022
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LPA toured the kitchen. LPA observed the locked medication cabinet and the locked cabinet with sharps. The refrigerator temperature was measured at 38 degrees F and the freezer was measured at 0- (-1) degree F. LPA observed 2 day perishable and 7 day non-perishable present.

The Carbon Monoxide detectors were present and properly operated. The fire and smoke detectors are observed in every room and observed to be operated properly, the fire extinguishers observed to be adequate. The first aid kit was observed to be present and completed. Extra linen was available. The Administrator reported that there is no firearms at the facility. LPA toured the garage which is locked at all times. Washer and dryer were observed to be in good working condition.

The Personal Policy Procedures, Facility Floor Plan, Emergency Disaster Plan, Labor Law and Ombudsman postings are posted by the main entrance. 30- day PPE supplies are present at the facility. There were no objects obstructing the emergency shut-offs: water, electricity (all locations are labeled) and gas shut-off stations. Facility sketch accurately reflects the floor plan.

Report is reviewed with Administrator/Licensee and a copy is provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
LIC809 (FAS) - (06/04)
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