<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294340
Report Date: 10/27/2022
Date Signed: 10/27/2022 11:20:14 AM


Document Has Been Signed on 10/27/2022 11:20 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:MOLDAW FAMILY RESIDENCES AT 899 CHARLESTONFACILITY NUMBER:
435294340
ADMINISTRATOR:ELYSE GERSONFACILITY TYPE:
741
ADDRESS:899 EAST CHARLESTON ROADTELEPHONE:
(650) 433-3600
CITY:PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:270CENSUS: 194DATE:
10/27/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Elyse GersonTIME COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) David Marrufo conducted a quarterly non-compliance visit and met with Administrator Elyse Gerson and Assistant Executive Director Preet Kaur.

LPA Marrufo reviewed the facility training logs that are part of the following facility non-compliance plan:

1. Licensee shall develop a plan in writing describing the training of facility staff on identifying and reporting residents’ change in conditions for timely appropriate medical attention.
2. Licensee shall develop a plan in writing describing the training of facility staff on observation and assessment of residents for any changes in physical, mental, emotional and social functioning to develop a plan of care to meet the resident’s needs.
3. Licensee shall develop a plan in writing describing training of facility staff on identifying prohibited and restricted health conditions and on submitting exception requests to the Department for residents with prohibited or restricted health conditions. Staff should be trained on when to retain a resident, when to request an exception request for the resident, and when to seek a higher level of care for the resident.
4. Licensing shall develop a plan in writing describing the facility protocol when readmitting residents to the facility from the hospital or skilled nursing facility. The plan should include re-appraisals of the resident and developing a new plan of care to meet the resident's needs.
5. Licensee shall develop a plan in writing describing how the personal rights of residents are not violated when resident exhibits wandering behavior, particularly for residents diagnosed with dementia.
6. Licensee shall develop a plan in writing describing the facility protocol to collaborate with other agencies such as hospice agencies and home health agencies to ensure that doctors' orders in the care of the resident are met.
7. Licensee shall develop a plan in writing describing the duties and responsibilities of the Administrator to ensure that resident's health conditions and needs area addressed. The plan shall include staff meetings to communicate resident health conditions and needs.

See LIC809-C for more information. Page 1 of 2.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
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


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: MOLDAW FAMILY RESIDENCES AT 899 CHARLESTON
FACILITY NUMBER: 435294340
VISIT DATE: 10/27/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA Marrufo observed training for the non-compliance plans were conducted on 08/16/2022, 08/30/2022, 10/11/2022, and 10/13/2022.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Assistant Executive Director Preet Kaur and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2