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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601141
Report Date: 08/08/2023
Date Signed: 08/08/2023 09:27:46 AM


Document Has Been Signed on 08/08/2023 09:27 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:
08/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Susan TilmaTIME COMPLETED:
09:30 AM
NARRATIVE
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On 8/8/2023, Licensing Program Analyst (LPS) Grace Donato conducted an unannounced case management visit. LPA met with Licensee, Susan Tilma. LPA explained the pruspose of the visit.

LPA received information regarding concerns about male caregiver (S1) “ripping clothes” of a female resident (R1). Another report regarding a resident (R2) eloping on 6/27/23.

On the concern about a S1 “ripping clothes” of R1, based on interviews, it cannot be confirmed that said incident happened due to R1 passing. R1 has been on hospice and has dementia.

With regards to R2 eloping, no record of the incident was reported to the facility. Based on interviews, Licensee mentioned that they weren't able to report the incident to CCLD. R2 likes walking around the facility. R2 was able to exit on one of the gates. On the day mentioned, R2 was able to go out unsupervised. Based on record reviews, resident has dementia and should not be able to leave the facility without supervision.

Deficiencies are cited today as the facility did not ensure the elopement incident was reported on a timely manner to CCLD. Also, the facility staff wasn't able to supervise the R2 while going around the facility leading him to leave unaccompanied/unsupervised.

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: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023
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 10/04/2023 02:35 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/04/2023 09:08 AM

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: 08/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2023
Section Cited
CCR
87705(h)

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Amended 87705(h)Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.This requirement was not met as evidenced by:
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Licensee to submit a plan and in-service training for staff about Dementia plan of operation of the facility. Licensee to submit to LPA by 8/9/23.
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Based on ord reviews and interviews, the licensee did not comply with the section cited above due resident with dementia being able to leave facility unassited which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
08/15/2023
Section Cited
CCR87211(a)(1)(D)

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Amended to Type A 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 was not met as evidenced by:
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Licensee to submit a plan of action regarding timely submission of incident reports. Licensee to submit to LPA by 8/15/23.
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Based on record reviews and interviews, the licensee did not comply with the section cited above due incidents not being reported to CCLD 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: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2