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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601141
Report Date: 09/18/2023
Date Signed: 09/18/2023 05:36:18 PM


Document Has Been Signed on 09/18/2023 05:36 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
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: 4DATE:
09/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Jonathan MendozaTIME COMPLETED:
05:05 PM
NARRATIVE
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On 9/18/23 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Caregiver Jonathan Mendoza. 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. At around 11:30 am, the residents were observed to have lunch in dining area.. While touring the facility it was observed that the room temperature was at 71 deg F. Hot water was also tested in the bathrooms and the temperature was 108 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.

Two resident records and two 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 interviewed two residents and one staff member. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

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

Upon reviewing resident records it was found out that an incident wasn't reported to CCLD. A resident (R1) was sent to ER and no incident report was done or sent to CCLD.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2023
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 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: 09/18/2023
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A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $250 for repeat violation regarding reporting requirements. Please see LIC421FC.

This report was reviewed with and a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/18/2023 05:36 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
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: 09/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87211(a)(1)(D)

87211(a) Each licensee shall furnish... such reports... including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency...(D)Any incident which threatens the welfare...or unexplained absence of any resident.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews and interviews, the licensee did not comply with the section cited above due incident not being reported to CCLD which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2023
Plan of Correction
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Licensee to submit a plan in order to address reporting requirements to CCLD. Licensee to submit plan by POC due date.
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.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2023
LIC809 (FAS) - (06/04)
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