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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601141
Report Date: 10/25/2022
Date Signed: 10/25/2022 11:57:41 AM


Document Has Been Signed on 10/25/2022 11:57 AM - 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 LLCFACILITY NUMBER:
415601141
ADMINISTRATOR:TILMA, SUSANFACILITY TYPE:
740
ADDRESS:1239 MIDDLE AVETELEPHONE:
(650) 796-9921
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:6CENSUS: 5DATE:
10/25/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Administrator, Susan TilmaTIME COMPLETED:
12:10 PM
NARRATIVE
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On 10/25/2022, Licensing Program Analyst (LPA), Murial Han met with the Administrator, Susan Tilma and conducted an unannounced Pre-Licensing inspection.

LPA observed the indoor and the outdoor passageways are free of obstruction.

LPA toured facility and grounds. This is a single level facility. The facility has 6 private resident rooms, 3 staff rooms, 2 resident bathrooms, 1 visitor bathroom and 1 staff bathroom. There is 5 residents during the time of the inspection. LPA observed good lighting and comfortable temperature in the facility. The living room and the dining room is observed to be comfortable, spacious with adequate furniture. LPA observed sufficient hygiene and cleaning supplies. The refrigerator was measured at 35 degrees Fahrenheit (F) and the freezer was measured at 0 degrees F. Dry goods/emergency food supplies are stored in the garage..

LPA observed COVID-19 signs posted by the entrance, within the facility, hand washing instruction signs by the hand washing stations and other postings such as the Licensing Complaint Poster, Resident Rights, etc.

Pre-Licensing is incomplete during this inspection due to the following observations:

- Medication is stored at a centralized area, however, it was not properly locked
- Chemicals, disinfectants, cleaning solutions, etc. are not properly locked
- Facility did not have a first aid kit
- The facility did not have a thermometer to measure the hot water temperature

The administrator acknowledged the above findings and LPA recommended the facility to review the pre-licensing checklist prior to the follow-up inspection.

Deficiencies for today's findings will be cited under facility Orchid Villa Residential Home, facility # 410508820.

Exit interview conducted with administrator. A copy of this report is provided
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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 3


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: 415601141
VISIT DATE: 10/25/2022
NARRATIVE
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The administrator acknowledged the above findings and LPA recommended the facility to review the pre-licensing checklist prior to the follow-up inspection.

Deficiencies for today's findings will be cited under facility Orchid Villa Residential Home, facility # 410508820.

Exit interview conducted with administrator.

A copy of this report is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/25/2022 11:57 AM - 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: 415601141

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2022
Section Cited

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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...8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available....
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This requirment is not met as evicenced by: the facility did not have a first aid kit for LPA to inspect during the pre-licensing inpsection which poses a potential health risk to residents in care.
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The administrator will submit proof that the first aid kit is obtained, properly stored and provide a copy of the in-service record to CCL by 11/1/2022.

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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3