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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430700136
Report Date: 07/02/2025
Date Signed: 07/02/2025 01:27:00 PM

Document Has Been Signed on 07/02/2025 01:27 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:CHANNING HOUSEFACILITY NUMBER:
430700136
ADMINISTRATOR/
DIRECTOR:		RHONDA BEKKEDAHLFACILITY TYPE:
741
ADDRESS:850 WEBSTER STREETTELEPHONE:
(650) 327-0950
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY: 264CENSUS: 226DATE:
07/02/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Elvyra AbareTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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On July 02, 2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident visit regarding an incident that occurred on 06/26/2025 when the resident (R1) was administered the incorrect medication by a staff member. Upon arrival, LPA met with the Chief Operating Officer (COO), Elvyra Abare and Assistant Administrator (AAD), Beth Shirley. The LPA disclosed the purpose of the visit.

LPA interviewed three (3) staff members: S1, S2, and AAD.

The AAD stated that at around 5 pm on 6/26/2025, S1 was carrying two medication cups: one to administer to R1 and the other for another resident. While S1 administered R1’s medication, S1 sat down with the cup holding the other resident's medication on R1's bedside table. S1 then left R1’s room. S2 then went into the R1 to give R1 some juice because R1’s blood sugar was low. Once in the room, S2 saw the cup with the other resident's medication in it and administered it to R1 in error, thinking it was R1’s medication. AAD stated that on 07/01/2025, both S1 and S2 had completed re-training on Relias for medication administration.

LPA interviewed S1 over the phone. S1 stated that they administered the wrong medication to R1. S1 stated that R1’s blood sugar was low, and they went to fetch the orange juice to raise the blood sugar. S1 informed S2 that they need assistance in giving juice and medication to R1. S1 left the room and by the time they realized the mistake, S2 had already administered the wrong medication to R1. S1 stated they contacted R1’s family member and PCP at Kaiser. The Kaiser nurse followed their protocols and advised S1 to monitor R1 for any adverse effects and change in condition, and PCP would contact if they had any questions. S1 stated R1 didn’t have any side effects or adverse reaction due to the wrong medication.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: CHANNING HOUSE
FACILITY NUMBER: 430700136
VISIT DATE: 07/02/2025
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LPA interviewed S2 over the phone. S2 stated that S1 mentioned that R1’s blood sugar was low and asked S2 to fetch orange juice for R1. S1 further asked S2 to give R1 their medications that were left on R1’s bedside. S2 gave the juice and the medication to R1 assuming the medication was for R1. S2 stated that S1 reached out to R1’s PCP and family about the medication error.

LPA reviewed R1’s progress notes for 06/26/2025, which documented the medication error. The notes indicated R1's vital readings and the exchange with the Kaiser nurse and R1’s family member.

LPA visited R'1 room to interview R1, but R1 was observed to be sleeping at that time.

The deficiencies are being cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, and Plans of Correction were reviewed and developed with the Assistant Administrator. A copy of this report and appeal rights were discussed and provided to the Assistant Administrator, Beth Shirley, whose signature on this form confirms receipt of these documents.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/02/2025 01:27 PM - It Cannot Be Edited


Created By: Kiran Jain On 07/02/2025 at 01:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CHANNING HOUSE
FACILITY NUMBER: 430700136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/03/2025
Section Cited
CCR
87465(h)(5)

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications… (5) Each resident's medication shall be stored… No medications shall be transferred between containers.
This requirement was not met as evidenced by:
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The AAD will submit the POC to CCLD by 07/03/2025.
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Based on interviews and records review, the facility staff did not ensure R1 was given the correct medication as staff was transferring multiple residents' medications at the same time from the originally received container/bubble packs to small cups.
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Kiran Jain
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
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