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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601141
Report Date: 11/04/2024
Date Signed: 11/04/2024 04:53:22 PM

Document Has Been Signed on 11/04/2024 04:53 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:
415601141
ADMINISTRATOR/
DIRECTOR:
TILMA, SUSANFACILITY TYPE:
740
ADDRESS:1239 MIDDLE AVETELEPHONE:
(650) 796-9921
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
11/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:57 PM
MET WITH:Ricardo AbanTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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On 11/4/2024, LPA Grace Donato made an unannounced annual visit to the facility. LPA met Co-Administrator Ricardo Aban. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas, kitchen area & garage. The indoor and outdoor passageways were free of obstruction. While touring the facility it was observed that the room temperature was at 69 deg F. Hot water was also tested in the bathrooms and the temperature was 110 deg F. Carbon monoxide monitor are working properly. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid mats. All personal belongings of residents are intact. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every quarter.

Five resident records and four staff records were reviewed. Staff records are complete, with training logs. Facility accepts hospice residents and are in compliance with the required waiver requirements.

LPA requested the following documents: LIC 308, Control of Property, Certificate of Liability Insurance, LIC 500, LIC610E.

Upon reviewing resident records it was found out that three out of five residents have a clause in their admission agreement about refunds. Clause states that "Residents on Respite Care and or Hospice Care: No refunds are offered due to uncertainty length of stay and of resident's condition." The facility’s admission agreement does not meet Title 22, Div. 6, Chapt. 8, Article 9, Sec. 87507 Admission Agreements.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed and copy of report and appeal rights are provided.
Andrea MedlinTELEPHONE: (650) 266-8811
Grace DonatoTELEPHONE: (714) 293-8294
DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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 11/04/2024 04:53 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: SANDHILL ASSISTED LIVING LLC

FACILITY NUMBER: 415601141

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above due R1, R2, R3s admission agreements have a clause regarding not providing refund of fees upon death, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2024
Plan of Correction
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Facility administrator to submit a plan of action to licensing by 11/11/2024 to describe how facility plans to provide the refund per regulations or as required to family member and refund policy moving forward. In additional facility to submit a revised admission agreement to meet CCR 87507(g)(5)(A) by 11/11/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Andrea MedlinTELEPHONE: (650) 266-8811
Grace DonatoTELEPHONE: (714) 293-8294

DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024

LIC809 (FAS) - (06/04)
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