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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601137
Report Date: 02/22/2024
Date Signed: 02/22/2024 06:14:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/27/2022 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220927160827
FACILITY NAME:SANDHILL ASSISTED LIVING LLCFACILITY NUMBER:
415601137
ADMINISTRATOR:TILMA, SUSANFACILITY TYPE:
740
ADDRESS:735 MONTE ROSA DRIVETELEPHONE:
(650) 492-9429
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:6CENSUS: 6DATE:
02/22/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Rick Aban, Aljolyn Maquiddang & Susie HerreraTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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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
INVESTIGATION FINDINGS:
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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
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 9
Control Number 14-AS-20220927160827
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SANDHILL ASSISTED LIVING LLC
FACILITY NUMBER: 415601137
VISIT DATE: 02/22/2024
NARRATIVE
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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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 14-AS-20220927160827
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SANDHILL ASSISTED LIVING LLC
FACILITY NUMBER: 415601137
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2024
Section Cited
CCR
87411(d)
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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.
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Licensee to submit a plan where staff are provided adequate on-the-job training. Licensee to submit plan by POC deadline.
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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.
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Type A
02/22/2024
Section Cited
CCR
87465(a)(4)
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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.
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Licensee to submit a plan to address medication administration to residents. Licensee to submit plan by POC deadline.
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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.
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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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 14-AS-20220927160827
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SANDHILL ASSISTED LIVING LLC
FACILITY NUMBER: 415601137
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2024
Section Cited
CCR
87411(a)
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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. ...
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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.
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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.
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Type A
02/23/2024
Section Cited
CCR
87555(b)(14)
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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...
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Licensee to submit a plan regarding food preparation in the facility. Licensee to submit plan by POC deadline.
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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.
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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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 14-AS-20220927160827
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SANDHILL ASSISTED LIVING LLC
FACILITY NUMBER: 415601137
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2024
Section Cited
CCR
87466
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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...
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Licensee to submit a plan addressing documentation and resident observation. Licensee to submit plan by POC deadline.
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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.
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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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/27/2022 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220927160827

FACILITY NAME:SANDHILL ASSISTED LIVING LLCFACILITY NUMBER:
415601137
ADMINISTRATOR:TILMA, SUSANFACILITY TYPE:
740
ADDRESS:735 MONTE ROSA DRIVETELEPHONE:
(650) 492-9429
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:6CENSUS: 6DATE:
02/22/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Rick Aban, Aljolyn Maquiddang & Susie HerreraTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident suffered from dehydration, which resulted in fall
Resident's hygiene needs are not being met
INVESTIGATION FINDINGS:
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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 of resident (R1) suffered from dehydration, which resulted in fall, the reporting party (RP) stated that it was determined by a hospice nurse that the fall was due to resident being dehydrated and low blood pressure.

LPA interviewed staff members and one staff member, S3, mentioned that residents are provided hydration during meals and snack time. They are also provided water when residents ask for it. There is no way to dete
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 14-AS-20220927160827
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SANDHILL ASSISTED LIVING LLC
FACILITY NUMBER: 415601137
VISIT DATE: 02/22/2024
NARRATIVE
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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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/27/2022 and conducted by Evaluator Grace Donato
COMPLAINT CONTROL NUMBER: 14-AS-20220927160827

FACILITY NAME:SANDHILL ASSISTED LIVING LLCFACILITY NUMBER:
415601137
ADMINISTRATOR:TILMA, SUSANFACILITY TYPE:
740
ADDRESS:735 MONTE ROSA DRIVETELEPHONE:
(650) 492-9429
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:6CENSUS: 6DATE:
02/22/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Rick Aban, Aljolyn Maquiddang & Susie HerreraTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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9
Staff does not safeguard resident's personal items
Facility meals do not meet dietary requirements
Planned activities are not sufficient
INVESTIGATION FINDINGS:
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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 of staff does not safeguard resident’s personal items, reporting party (RP) stated that the facility lost the resident’s (R1) hearing aid.

According to interview, a staff member (S3) mentioned that the hearing aid was found by another staff member (S4) in the bathroom. Based on records review, the hearing aid is not included in form for Resident Personal Property and Valuables (LIC621).
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 14-AS-20220927160827
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SANDHILL ASSISTED LIVING LLC
FACILITY NUMBER: 415601137
VISIT DATE: 02/22/2024
NARRATIVE
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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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 9 of 9