Sandhill Assisted Living

Type of visit: Required - 1 Year

On July 1, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. Upon entry, LPA met with house manager, Enrico Ortega and explained the purpose of today's visit. The administrators, Susan Tilma and Ricardo Aban arrived shortly thereafter and assisted with the inspection. LPA received a tour from the house manager and observed the indoor and the outdoor passageways are free of obstruction. This is a single story facility with 7 bedrooms (5 resident rooms and 2 staff room) and 4 bathrooms. There were 5 residents and 3 staff present during the visit. The facility is observed to be spacious, clean, and odor-free with comfortable temperature. Hot water temperature in the kitchen and resident's bathroom was measured at 128-130 degrees F. LPA observed medication, sharps, and toxins were locked and inaccessible to resident's in care. 2 days of perishables and 7 days of nonperishable foods were observed for the residents. Facility is equipped with smoke detectors and carbon monoxide detectors. Fire drill records were observed to be insufficient. A review of (5) resident files was conducted and noted on LIC 858. A review of (3) staff files was conducted and noted on LIC 859. Deficiencies are cited under California Code of Regulations, Title 22, cited on the LIC 809-D. Failure to correct the deficiencies may result in civil penalties. This report was reviewed with Administrators, Ricardo Aban, and Susan Tilma and a copy of the report along with Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jul 1, 2026

Type of visit: Required - 1 Year

On 7/10/2025, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Co-Administrator Ricardo Aban. LPA explained the purpose of the visit. LPA toured the facility inside and outside including all of resident rooms, garage, and kitchen area. Facility is a single story home with six resident bedrooms. LPA observed residents in the living room. While touring the facility it was observed that the room temperature was at 70 deg F. Hot water was also tested in the bathrooms and the temperature was 118 deg F. The facility is observed to be clean, odorless, and well maintained. Residents bedrooms were observed to be well organized and fully furnished with adequate lighting. Sharps and toxic materials were observed locked. Food supply in kitchen and garage refrigerator was observed with an adequate two day perishable and seven day non-perishable food supply. Carbon monoxide/ smoke detectors, and fire extinguisher were present throughout the facility. Facility has an updated log for emergency drill is done every quarter. Four resident records and four staff records were reviewed. Centrally stored medication was locked and inaccessible by residents. All medication was labeled and sorted by resident name. All medication logs are complete and updated. LPA received the following documents: Liability Insurance & LIC500. No deficiencies cited today. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Jul 10, 2025

Type of visit: Case Management - Other

On April 10, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to deliver a copy of amended LIC9099D. LPA met with Administrator, Ricardo Aban and explained the purpose of the visit. During the visit, LPA delivered a copy of LIC9099D in relation to complaint control: 14-AS-20250129110008. Report is reviewed with Administrator, Ricardo Aban and a copy is provided.the state’s words, verbatim · CDSS document, Apr 10, 2025

Type of visit: Case Management - Other

On April 10, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit in relation to a hospice waiver increase. LPA met with Administrator, Ricardo Aban and explained the purpose of the visit. On 4/1/24, LPA received a hospice waiver increase. During the visit, LPA observed 5 residents; two of which were in the living room, three in their bedrooms. LPA observed three caregivers on site. No citations are issued during the visit. Report is reviewed with administrator and a copy is provided.the state’s words, verbatim · CDSS document, Apr 10, 2025

Allegation investigated: Licensee is not ensuring that the facility has sufficient staff to meet the needs of residents in care.

On 2/19/2025 Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit at the facility. LPA met with Administrator Susan Tilma and explained the purpose of the visit. Regarding Licensee is not ensuring that the facility has sufficient staff to meet the needs of residents in care, according to the reporting party, there are 5 residents at the facility and either 1 or 2 staff members present at to provide care and supervision throughout the day. During the complaint visit on 1/31/25, LPA observed 5 residents in their beds and one staff member (S1) cooking breakfast. LPA reviewed all 5 resident files and observed 4/5 residents to have a diagnosis of dementia and one resident that is on hospice. According to the administrator and S1, from 8-9am, S1 is providing care and supervision to the 5 residents. When S1 goes on his/her break from 11am-1pm, there is another staff member (S2) who is providing care and supervision to 5 residents alone. Therefore, based on the interviews conducted and information collected, the above allegations are determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed. A copy of the report and appeal rights are provided. Substantiatedthe state’s words, verbatim · CDSS document, Feb 19, 2025 · control 14-AS-20250129110008

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Feb 26, 2025

87411 Personnel Requirements – General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents... This requirement was not met as evidenced by: Based on interviews, observations and records review, there was not enough staff member scheduled to cater to the resident’s care which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: On 4/10/25, LPA delivered amended LIC9099D. LPA conducted visit on 4/10/25 and observed sufficient staff. Deficiency corrected and cleared.

Type of visit: Case Management - Legal/Non-compliance

On 8/22/24, Licensing Program Analysts (LPAa), Grace Donato & Kiran Jain conducted an unannounced case management- legal/non-compliance inspection to monitor the facility operation. LPA met with Administrator, Ricardo Aban and explained the purpose of the visit. A non-compliance conference was held on October 4, 2023. During non-compliance meeting, the following violations were discussed Personal Rights of Residents in All Facilities, Personnel Records, Emergency Drills, Reporting Requirements. During LPAs visit it was observed that residents just finished breakfast. No dogs in the facility. First Aid training's are updated. Emergency drill training was done using Fire Department of Menlo Park and was conducted on July 2024. Reporting requirements has been followed, Facility is constantly reporting incidents. No citations issued today. Report is reviewed with Administrator and a copy is provided.the state’s words, verbatim · CDSS document, Aug 22, 2024

Type of visit: Case Management - Legal/Non-compliance

On 8/22/24, Licensing Program Analysts (LPAs), Grace Donato & Kiran Jain conducted an unannounced case management- legal/non-compliance inspection to monitor the facility operation. LPA met with Administrator, Ricardo Aban and explained the purpose of the visit. A non-compliance conference was held on October 4, 2023. During non-compliance meeting, the following violations were discussed Reporting Requirements, Care of Persons with Dementia, Personnel Requirements. During LPAs visit, it was observed that care staff are currently doing some ADLs (Activities of Daily Living) for a resident. Some residents are also resting in their respective rooms. Care of Persons with dementia training is still up to date. Facility is consistent with reporting requirements, staff has been constantly reporting incidents and then submitted to Licensing. Staffing is currently enough to cater to residents in the facility. No need for night shift at the moment but will be addressed by Licensee if needed. No citations issued today. Report is reviewed and a copy is provided.the state’s words, verbatim · CDSS document, Aug 22, 2024

Type of visit: Case Management - Annual Continuation

On August 1, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 8:30 am to complete the Annual 1-year required inspection started on July 25, 2024. LPA Calandra was greeted by Ricardo Aban, Administrator and explained the purpose of the visit. LPA Calandra toured the physical plant. This is a 1-story building with 6 bedrooms, two bathrooms, a staff bedroom and staff bathroom, garage, dining room, living room, kitchen, front and back yards. The facility was maintained at a comfortable temperature of 71 degrees Fahrenheit. No accessible bodies of water or hazards were observed. Hot water temperature was measured within the required range of 105-120 degrees Fahrenheit. The facility's fire extinguishers were last checked on June 1, 2024 and were observed to be fully charged. No food was observed to be expired except for one item which was discarded in the presence of the LPA. The facility had the required 7 days of non perishables and 2 days of perishables on site. The facility's smoke detectors and carbon monoxide detector were observed to be in working order. The facility's first aid kit had the required tweezers, bandages, scissors, thermometer, and guide. A Technical violation was provided for not ensuring that all food is stored in covered containers. A Technical violation was provided for not recording each hospice led training session. A Type B violation was provided for not having screened fireplaces. A Type B violation was also provided for not notifying licensing that exterior gates are locked. Deficiencies are cited under California Code of Regulations, Title 22, cited on the LIC 809-D. Failure to correct the deficiencies may result in civil penalties. An exit interview was conducted. This report was reviewed with Ricardo Aban, Administrator and a copy of the report along with Appeal rights left at the facility.the state’s words, verbatim · CDSS document, Aug 1, 2024

Type of visit: POC

On August 1, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 3:00 PM to conduct a Plan of Correction(POC) visit in regards to a citation regarding medications and failure to correct issued on July 25, 2024. LPA Calandra was greeted by Ricardo Aban, Administrator and explained the purpose of the visit. As of August 1, 2024, the deficiency has been cleared. An exit interview was conducted this report was reviewed with Ricardo Aban, Administrator and a copy of the report left at the facility.the state’s words, verbatim · CDSS document, Aug 1, 2024

Type of visit: Required - 1 Year

On July 25, 2024, Licensing Program Analysts(LPAs) John Calandra and Kiran Jain arrived at the facility to conduct the unnanounced Annual 1-year required inspection at 8:50 AM. LPAs Calandra and Jain were greeted by Inahxylene Ortega, Caretaker and explained the purpose of the visit. Enrico Ortega, Lead Caregiver arrived later along with Susan Tilma, Licensee and Ricardo Aban, Administrator. LPAs Calandra and Jain reviewed 5 resident records and 5 staff records. All were observed to be complete. LPAs Calandra and Jain also reviewed Centrally Stored Medications Records(CSMR). A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day but did not match the Centrally Stored Medication Records(CSMR) kept at the facility. A Type A Violation was provided for not having medications for residents recorded in the Centrally Stored Medication Records kept at the facility. A Type A Violation was also provided for not having supplies available to provide alternative resources during an outage. A Technical Violation was provided for not having a key to the facility vehicle on site for emergencies. This Annual will be completed at a later date. Deficiencies are cited under California Code of Regulations, Title 22, cited on the LIC 809-D. Failure to correct the deficiencies may result in civil penalties. An exit interview was conducted. This report was reviewed with Ricardo Aban, Administrator and a copy of the report along with Appeal Rights left at the facility.the state’s words, verbatim · CDSS document, Jul 25, 2024

Type of visit: Case Management - Legal/Non-compliance

On 5/24/24, Licensing Program Analyst (LPA), Grace Donato conducted an unannounced case management- legal/non-compliance inspection to monitor the facility operation. LPA met with Administrator, Ricardo Aban and explained the purpose of the visit. A non-compliance conference was held on October 4, 2023. During non-compliance meeting, the following violations were discussed Personal Rights of Residents in All Facilities, Personnel Records, Emergency Drills, Reporting Requirements. During LPAs visit it was observed that residents were being prepped and breakfast is served in dining area.. No dogs in the facility. First Aid training's are updated. Emergency drill training was done using Gerboth Fire & Safety Inc. and has just been conducted. Reporting requirements has been followed, Facility is constantly reporting incidents. No citations issued today. Report is reviewed with Administrator and a copy is provided.the state’s words, verbatim · CDSS document, May 24, 2024

Allegation investigated: Only one staff was scheduled and unable to communicate due to language barrier

On 3/22/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Caregiver Dinnah Ortega and explained the purpose of today's visit. Regarding the allegation of only one staff was scheduled and unable to communicate due to language barrier, the Reporting Party (RP) stated that RP arrived at the facility to visit a relative. RP attempted to communicate with the only caregiver on the premises but was unable to do so due to a language barrier. Based on interviews, LPA was able to interview one family member (F1). They stated that they don’t remember a situation where they were not able to communicate with staff. Two staff members were interviewed, and both confirmed that the staff (S1) working that day can understand and speak English. Based on interviews, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. No citations for today. Report is reviewed and copy is provided. Unfoundedthe state’s words, verbatim · CDSS document, Mar 22, 2024 · control 14-AS-20240312113322

Allegation investigated: Staff have not received required training Staff interfered with administration of medications prescribed by MD Staffing is inadequate to meet residents' care needs Meals are not prepared on site Resident's weight loss was not documented nor reported to MD and responsible party accurately

On 2/22/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegations. LPA met with Caregivers Aljolyn Maquiddang & Susie Herrera then Administrator Rick Aban followed after. LPA explained the purpose of the visit. Regarding the allegation Staff have not received required training, the reporting party (RP) states that staff are asked to sign a document for training that was taken; however, training was never done. During the investigation, LPA Jeung interviewed two staff members one (S1) mentioned that they did get trained on dementia, emergency preparedness, lifting, as well as other topics. And this was done online and in person. However, two out of four family members that were interviewed said that there are staff that are not qualified and not trained. The first witness (F1) mentioned an instance where a staff (S2) was not able to care for a resident (R2); they would have to wait for senior staff to come to change the diaper. Another witness (F2) also mentioned that a staff (S1) had to ask for toothpaste from him/her when S1 should have known that this is supplied by the facility. F2 requested another staff to take care of the resident (R3). Substantiated Regarding the allegation that staff interfered with administration of medications prescribed by medical doctor, RP stated that the resident (R1) was over medicated and was provided an increase dosage of Zoloft for two days. Based on record reviews, according to the R1s centrally stored medication record, Zoloft is to be administered one tablet a day with 25mg dosage. On the medication administration record (MAR) for the month of September 2022 there was one day where R1 was given twice the dosage of the medication. No other documentation stating that it was approved by R1s physician. Regarding the allegation of staffing is inadequate to meet residents' care needs, RP stated that there are not enough staff to meet clients’ needs and to supervise them. There is only one caregiver during the day hours between 8:30 am to 9pm. LPA Jeung interviewed two staff members and one staff member (S3) mentioned that when R1 fell he/she was not able to assist right away as there is another resident being helped in the bathroom. Based on records review, the LIC 500 or Personnel report schedule, dated October 19, 2022, only stated the number of days and time that a staff member works. No specific days are stated. Regarding the allegation of meals are not prepared on site,RP stated that meals are not prepared on site. According to an interview with a staff member (S3), breakfast and dinner are prepared on site. However, lunch is made in the other facility, Sandhill in Middle Ave, two to three times a week. The food is contained in plastic containers and just delivered by another staff member (S4) to the facility by car. Regarding the allegation of resident's weight loss was not documented nor reported to medical doctor and responsible party accurately, RP states that R1 has lost significant amount of weight in 2-3 months. From 115lbs to 87lbs. LPA Donato asked the facility for weight loss records but was not able to produce said documentation. Therefore, based on the interviews conducted and information collected, the above allegations are determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Regarding the allegation of resident's hygiene needs are not being met, (RP) mentioned that staff do not change the (R1) and is left in pajamas. RP also stated that when he/she went to visit, R1 was still in pajamas and had not been cleaned up as R1s face was oily from the night and glasses were dirty. Based on interviews, three out of four family members mentioned that they don’t have concerns about grooming and dressing for the residents. A family member (F3) of R1, stated that resident was always dressed and doesn’t care if he/she has pajamas on. Another family member (F4) also mentioned that they don’t have concerns about the residents (R2) personal care. Based on interviews, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No citations for today. Report is reviewed and copy is provided. For the allegation of facility meals doesn’t meet dietary requirements, RP stated that facility is not serving quality food. RP was interviewed and mentioned that R1 is a picky eater. It was also mentioned that R1 said that the meals are unappetizing. According to records review, facility provides family member a copy of the menu that are being served to the residents. One family member (F1) mentioned during an interview that R2 doesn't like the food, so they bring cooked food. Another family member, F2, stated that the resident R3 likes the food; there are lots of fruits, vegetables, and salads, and they don't serve processed foods from cans. F4 also stated that R4 likes the food and that fruits are available. LPA Donato also observed during several visits that the facility does provide food. Dishes come with protein, soup and fruits. Facility also provides snacks as scheduled and when residents ask for it. Regarding the allegation of planned activities are not sufficient, RP stated that there are no activities available to residents. During RPs interview, it was mentioned that there is an exercise activity that is performed in the morning but nothing else is offered to any of the residents in the community. LPA Jeung also interviewed family members and three out of four said that the residents are not interested or prefers to do something else. F4 mentioned that R4 prefers to read and watch TV. The other two residents, R1 and R3 are not interested. F1 mentioned that there are no activities. Staff members were also interviewed and S3 stated that no activities are facilitated because residents don’t want to do it. Sometimes, S3 takes residents for a walk in the yard or turns on "Sit and be Fit" on the television so clients can participate. Based on records review, the facility has a list of activities that can be facilitated every day. Based on interviews, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. No citations for today. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Feb 22, 2024 · control 14-AS-20220927160827

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(d) · Plan of correction due date: Feb 23, 2024

87411 Personnel Requirements –General (d)All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance. This requirement is not met as evidenced by: Based on interviews from witnesses, there are staff that are not qualified and not trained, which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: Licensee to submit a plan where staff are provided adequate on-the-job training. Licensee to submit plan by POC deadline.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 22, 2024

87465 Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance... (4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records review, there was one day where R1 was given twice the dosage of the medication and no other documentation stating that it was approved by R1s physician, which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: Licensee to submit a plan to address medication administration to residents. Licensee to submit plan by POC deadline.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Feb 23, 2024

87411 Personnel Requirements – General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. ... This requirement is not met as evidenced by: Based on interviews and records review S3 was not able to help R1 due to another resident being assisted and the personnel report schedule have no specific days on when staff is scheduled, which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: Licensee to submit a plan to provide adequate staffing in the facility. Licensee to submit updated LIC 500. Licensee to submit plan by POC deadline.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(14) · Plan of correction due date: Feb 23, 2024

87555 General Food Service Requirements (b)The following food service requirements shall apply (14) If food is prepared off the facility premises, the preparation source shall meet all applicable requirements for commercial services... This requirement is not met as evidenced by: Based on interviews, lunch is prepared in a different facility and placed in plastic containers and transported by another staff member by car, which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: Licensee to submit a plan regarding food preparation in the facility. Licensee to submit plan by POC deadline.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Feb 23, 2024

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses... This requirement is not met as evidenced by: Based on interviews, the facility is not able to provide any records regarding R1s weight loss, which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: Licensee to submit a plan addressing documentation and resident observation. Licensee to submit plan by POC deadline.

Allegation investigated: Staff do not ensure that the facility has a working telephone at all times Staff are preventing resident from receiving hospice services because they do not answer the facility door

On 2/22/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegations. LPA met with Caregivers Aljolyn Maquiddang & Susie Herrera then Administrator Rick Aban followed after. LPA explained the purpose of the visit. Regarding the allegations of staff does not ensure that the facility has a working telephone at all times and staff are preventing resident from receiving hospice services because they do not answer the facility door, reporting party (RP) stated that the hospice agency attempted to call the facility, but staff did not answer the telephone. Hospice staff attempted to visit the resident, but staff did not answer the door. Hospice staff continued to call and attempt to visit but were unable to gain access to the resident (R1) until 11/29/2022. LPA Jeung was able to interview three staff members, S1 stated that staff do not want to answer the phone because they don't know what to say and they're shy. Instead of answering the phone, they will give the phone to senior caregivers. Another staff member, S2 advised that it works all the time, and that they answer it when it rings. S2 also stated that there was power outage the week before 12/07/2022 between 8pm until 2am. However it was not mentioned what the exact day was. S3 did not mention anything regarding telephone calls. Unsubstantiated Based on records review, a hospice visit log was provided, and it indicated that the visit’s happened on 11/25/2022, 11/29/2022, 11/30/2022. There was also a report that hospice was supposed to be at the facility on 11/27/2022 with an arrival time of 9pm. On this report it was noted that the power outage happened from 11:30pm to 2am. Based on interviews, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No citations for today. Report is reviewed and copy is provided. Regarding the allegation of staff are not competent to meet client's needs, RP stated that R1s abdomen was descended and staff was unable to tell the RP when the resident's last bowel movement was. S1 stated that there were no logs or documentation regarding the resident’s bowel movement. Unless they remember when it was. Therefore, based on the interviews conducted and information collected, the above allegations are determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.the state’s words, verbatim · CDSS document, Feb 22, 2024 · control 14-AS-20221129135944

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(d)(2) · Plan of correction due date: Feb 23, 2024

87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication...(2) The date and time of each contact with the physician, and the physician's directions... This requirement is not met as evidenced by: Based on records review, two medications, Lasix & Tylenol, were given to R1 with no proper documentation that it was requested from the doctor, which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: Licensee to submit a plan to address documentation of PRN medications to residents. Licensee to submit plan by POC deadline.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(c) · Plan of correction due date: Feb 23, 2024

87411 Personnel Requirements - General(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not met as evidenced by: Based on interview, S1 stated that there were no logs for activities of daily living, which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: Licensee to submit a plan to address documentation of activities of daily living. Licensee to submit plan by POC deadline.

Type of visit: Case Management - Health Checks

On 2/22/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management visit. LPA met with Caregivers Aljolyn Maquiddang & Susie Herrera then Administrator Rick Aban followed after. LPA explained the purpose of the visit. LPA toured the facility, and it was observed there is not enough food supply when the current census is six. There is not enough canned food and non-perishable foods. LPA also observed that a new resident (R1) doesn't have a the required paperwork. It was however produced when LPA asked for documentation. LPA interviewed a staff (S1) and it was mentioned that they are not aware about the health issues that R1 has. They were just informed that the facility will have a move in. LPA checked the Medication Administration Records (MAR) for R1 and there was documentation. 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. This report was reviewed with and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Feb 22, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(1) · Plan of correction due date: Feb 23, 2024

87405 Administrator - Qualifications and Duties (d)The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement is not met as evidenced by: Based on records review, R1 moved in and caregivers were not given any information regarding the resident, which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: Licensee shall submit a plan on how it will address dissimenating information regarding residents to caregivers. Licensee to submit plan by POC deadline.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(a)(6) · Plan of correction due date: Feb 23, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(6)When requested by the prescribing physician or the Department, a record of dosages ... This requirement is not met as evidenced by: Based on records review, R1 does not have a Medication Administration Records (MAR) log, which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: Licensee to submit a plan to address documentation regarding MAR. Licensee to submit plan by POC deadline.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(26) · Plan of correction due date: Feb 23, 2024

87555 General Food Service Requirements (b) The following food service requirements shall apply: (26)S upplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Based on observation, there was not enough supply of canned good and 7-day non-perishable foods, which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: Licensee to submit a plan to address the food supply in the facility. Licensee to submit photos of food supply. LIcensee to submit by POC deadline.

Type of visit: Case Management - Legal/Non-compliance

On 1/16/24, Licensing Program Analyst (LPA), Grace Donato conducted an unannounced case management- legal/non-compliance inspection to monitor the facility operation. LPA met with Administrator, Ricardo Aban and explained the purpose of the visit. A non-compliance conference was held on October 4, 2023. During non-compliance meeting, the following violations were discussed Personal Rights of Residents in All Facilities, Personnel Records, Emergency Drills, Reporting Requirements. During LPAs visit it was observed that residents were watching tv in the living room. The dogs are not in the facility anymore and were moved somewhere else. First Aid training's are updated. Emergency drill training was done using Gerboth Fire & Safety Inc. Reporting requirements has been followed, Facility is constantly reporting incidents. No citations issued today. Report is reviewed with Administrator and a copy is provided.the state’s words, verbatim · CDSS document, Jan 16, 2024

Type of visit: Case Management - Other

On 12/21/23 Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management visit. LPA met with Caregiver Aljolyn Maquiddang and explained the purpose of the visit. LPA checked if the Decision and Order to exclude and individual was followed effective today, 12/21/23. LPA toured and checked the facility and everything is clear. Individual is no longer in the premises. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Dec 21, 2023

Type of visit: Case Management - Health Checks

On 11/06/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit for case management visit for health checks. LPA met with Caregiver Susie Herrera. LPA explained the purpose of the visit. During the visit LPA observed the residents being prepped for lunch. Masking is required again in the facility. LPA also observed that there is only one caregiver on the premises. LPA reviewed three random resident files. LPA recommended the following: - have 2 caregivers scheduled every time, if there is a call out, make sure shift is covered. Upon review of resident file, LPA noticed that there was a change of condition for a resident (R1). A doctors report was noted saying that R1 had a rash. This change of condition wasn't reported to Licensing. Deficiency is being cited today as the facility did not ensure that residents R1s change in condition was reported to Licensing. Based on records review, R1 has rash and is still being monitored by the doctor. Facility is being cited for not following reporting requirements. 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.the state’s words, verbatim · CDSS document, Nov 6, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Nov 7, 2023

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: Based on record reviews licensee did not comply with the section cited above due an incident where there is a change in condition of R1 not reported to CCLD which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 6, 2023

Plan of correction: Licensee to submit a plan in order to address reporting requirements to CCLD. Licensee to submit plan by POC due date.

Type of visit: Office

On 10/4/23 San Bruno Regional Office conducted a non-compliance conference meeting with Licensees, Susan Tilma & Diana Covich. Present in the meeting was Regional Manager, Vivien Helbling, Licensing Program Manager, Jackie Jin, and Licensing Program Analyst, Grace Donato. During non-compliance meeting, the following violations were discussed, Personal Rights of Residents in All Facilities, Facility dog presented aggression toward a family member and bit the family member. Personnel Requirements – General and Personnel Records for records were not readily available in the facility. Administration and management of residential care facilities; substituted qualifications; employee scheduling, for two staff members doesn't have valid CPR training due to validity being expired. Emergency Plans for not having completed emergency drill log as required. Reporting Requirements for resident reported to Licensing that he/she fell several times and no incident report was submitted by the Licensee. During this meeting, it was discussed, Licensee will receive more frequent monitoring inspection visits to ensure compliance with this compliance plan and Title 22 Regulations for 2 years. Licensee was provided the link below for resources and guidance to improve facility operations: https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providersthe state’s words, verbatim · CDSS document, Oct 4, 2023