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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430700136
Report Date: 07/21/2025
Date Signed: 07/21/2025 12:36:19 PM

Document Has Been Signed on 07/21/2025 12:36 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
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: 231DATE:
07/21/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Elvyra AbareTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 07/21/2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident visit regarding an incident that occurred on 07/03/2025 when the resident (R1) eloped from the facility. 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 COO, who stated that R1’s wife (R2), was a resident of the Independent Living (IL) unit and took R1 out around 9:15 AM for AM exercise in the IL. Later around 11:45 AM, R1 called to let the Assisted Living (AL) staff know that R1 will be eating lunch with R2 at R2’s apartment at IL. R2 checked on R1 after lunch and observed R1 taking a nap. R2 took a nap as well and when R2 woke up, R1 was not in the room. A few minutes later, a private caregiver of a resident at Skilled Nursing unit saw R1 walking alone and verbally notified the staff. The Assistant Director of Nursing and one of the CNA went and brought R1 back inside the Assisted Living. A head-to-toe assessment was done and R1 was put on 72 hours monitoring. Law enforcement was not involved.

COO stated that the facility held R1’s plan of care meeting with R2 and rest of R1's family members. The facility was offered an option of a private caregiver or family assisting R1 with the walks. The COO further stated that R1 likes to walk, and it would be good if R1 had a scheduled walk every day. The family decided to have R1 walk with their daughter who lives nearby. According to COO, the family stated that they are willing to sign whatever it takes for R1 to go out on walk on their own and offered to write a letter to the facility to indicate that family was liable for R1.

LPA reviewed past Incident Reports and observed that R1 had dementia and have eloped from the facility twice on the same day in February 2025.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2025
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: 07/21/2025
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The COO stated that the after R1's latest elopment incident, the facility has enforced the check-out and check-in procedure for R1 if anyone is taking R1 out of Assisted Living. R1 already have a wander guard bracelet on them. Additionally, R1’s family was going to provide and place an AirTag in R1’s shoes. The facility will continue to reassess R1’s well-being and safety by continuing R1’s safety discussions with R1’s family members.

No deficiencies were cited during today's visit.

An exit interview was conducted with the COO. A copy of this report was provided to the COO, Elvyra Abare, whose signature on this form confirms receipt of the report.

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

DATE: 07/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2025
LIC809 (FAS) - (06/04)
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