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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601141
Report Date: 09/01/2023
Date Signed: 09/02/2023 12:49:45 AM


Document Has Been Signed on 09/02/2023 12:49 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:
09/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Jonathan MendozaTIME COMPLETED:
02:15 PM
NARRATIVE
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On 9/1/2023, Licensing Program Analyst (LPS) Grace Donato conducted an unannounced case management visit. LPA met with Caregiver, Jonathan Mendoza. LPA explained the purpose of the visit.

LPA received an incident report last 8/29/23 regarding a resident (R1) eloping from the facility. The incident happened on 8/27/23, R1 eloped from the facility around 1am and was returned by Police around 2 am with no injuries. Staff (S1) that currently resides on the facility, but not on shift, did not hear the alarm went off around that time.

While LPA was in the facility, R1 was currently having lunch in the dining area. LPA observed that all exit points have a loud alarm when door is opened. Facility also has a main gate which is open the whole day and closed during nighttime. It is unknown which gate R1 used to exit the facility premises.
LPA spoke with Licensee, Diana Covich on the phone. There was no reassessment done for R1 after the elopement. Licensee has scheduled a reassessment for the resident.There is no night supervision scheduled in the facility. Based on document review, R1 has wandering behavior.

Deficiencies are cited today as the facility did not ensure that residents won’t be able to leave the facility without assistance. Facility also didn’t make sure that R1 had a reassessment after the incident, this is to address any additional care that might be needed. Facility is also being cited for not having night supervision available even when there is a resident who have wandering behavior.
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.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023
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 2


Document Has Been Signed on 09/02/2023 12:49 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: 09/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2023
Section Cited
CCR
87705(c)(5)(A)

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87705 (c)Licensees who accept and retain residents with dementia...(5)Each resident with dementia shall have an annual medical assessment... (A) When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed... This requirement was not met as evidenced by:

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Licensee to submit a plan of action and submit the reassessment report (whenever available) to LPA by POC deadline.
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Based on record reviews and interviews, the licensee did not comply with the section cited above due to R1 not being reassesed after the elopement which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
09/02/2023
Section Cited
CCR87705(c)(4)(A)

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87705(c) Licensees who accept and retain residents with dementia...(4)There is an adequate number of direct care staff...(A)In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents... This requirement was not met as evidenced by:

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Licensee to submit an updated LIC500 which states that there would be a night shift scheduled. Licensee to submit by POC due date.
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Based on record reviews and interviews, the licensee did not comply with the section cited above due to R1 having wandering behaviors but Licensee did not schedule nigh supervision which poses an immediate 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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2