Sandhill Assisted Living Llc
RCFE · Memory Care
A Residential Care Facility for the Elderly (RCFE) is a non-medical residential care home licensed by California CDSS under Health & Safety Code §1560. Residents receive help with daily living activities such as bathing, dressing, and medication management. An RCFE with a Memory Care designation is additionally required by California Title 22 (§87705 and §87706) to provide specialized staff training in dementia care, individualized care plans for residents with cognitive impairment, and appropriate supervision protocols — requirements that go beyond a standard RCFE license.
735 Monte Rosa Drive · Menlo Park, 94025
Quick facts
Quality snapshot
Updated April 25, 2026Compared to 182 California RCFE memory care facilities of similar size, over the last 36 months.
Source: California Department of Social Services, Community Care Licensing Division. View raw inspection records →
Quality grade· click to show how this was calculated
Severity6thWeighted citations per bed
Repeats100thRepeat deficiencies as share of total
Frequency60thDeficiencies per inspection
Tick mark at 50% = peer median · higher percentile = better facility
Quality grade· click to show how this was calculated
Weighted citations per bed
Repeat deficiencies as share of total
Deficiencies per inspection
Tick mark at 50% = peer median · higher percentile = better facility
Sandhill Assisted Living Llc scores C. Better than 55% of comparable California RESIDENTIAL CARE ELDERLY facilities. Severity: bottom 6%. Repeats: top 0%. Frequency: 60th percentile.
Each metric is converted to a 0–100 percentile within the peer set (higher = better). The composite grade averages all four. Peer set: CA / rcfe_memory_care / small beds (182 facilities).
Citation severity over time
↓ improvingWeighted severity score per month · 24 months
Weighted score (24mo)
36
Last citation
Feb 25
Finding distribution
19 total · 36 monthsScope × Severity (CMS A–L)
The rules that apply to this facility
California Title 22 requirements for this facility, with the specific regulation and a suggested question for each.Rules this facility has been cited for are shown first.
What dementia-care training must staff complete?Cited Aug 202422 CCR §87705 / HSC §1569.625
Because this facility markets dementia or Alzheimer's care, state law mandates higher training standards:
- 12 hours initial dementia training — 6 hours before a staff member works independently with residents, 6 more within the first 4 weeks.
- 8 hours annual dementia in-service — required every year thereafter.
- Administrator CE — the administrator must include 8 hours of dementia-specific continuing education in every 2-year recertification cycle.
Training must cover individualized care plans, behavioral expressions, appropriate supervision, and the facility's dementia care philosophy.
Ask on tour: Ask how dementia training records are kept — families may request documentation.
What must this facility report to the state — and how fast?Cited Nov 202322 CCR §87211 / WIC §15630
- ImmediateElopement, fire, epidemic outbreak, or poisoningImmediately
- 2 hoursAbuse with serious bodily injury2-hour phone report + 2-hour written report — to the California Department of Social Services (CDSS), Adult Protective Services, and law enforcement
- 24 hrsAbuse without serious bodily injuryWithin 24 hours
- Next dayDeath of a residentPhone by next working day; written within 7 days
- Next dayInjury requiring medical treatment beyond first aidPhone by next working day; written within 7 days
- WrittenBankruptcy, foreclosure, eviction, or utility shutoff noticeWritten notice to CDSS and residents — $100/day penalty (max $2,000) for failure
Your enforcement lever:Incidents that aren't reported on time are themselves a separate violation. If you believe a reportable event wasn't filed, you can submit a complaint directly to the California Department of Social Services (CDSS).
How many staff must be on duty overnight?22 CCR §87415
Based on 6 licensed beds:
One qualified staff member must be on call and physically on premises at all times overnight.
Violation pattern to watch for:A facility that documents a staff member as "on call" but with that person physically off-site — when the law requires on-premises presence — is in violation of this section.
Ask on tour: Ask the facility to walk you through their overnight staffing plan and confirm whether on-call staff are on premises or off-site.
What health conditions can this facility legally accept or refuse?22 CCR §87612–87615
Restricted — allowed with physician order + care plan
- Supplemental oxygen
- Insulin and injectable medications
- Indwelling or intermittent catheters
- Colostomy / ileostomy
- Stage 1 and Stage 2 pressure injuries
- Wound care (non-complex)
- Incontinence
- Contractures
Prohibited — facility must refuse or discharge
- Stage 3 or Stage 4 pressure injuries
- Feeding tubes (PEG, NG, or J-tube)
- Tracheostomies
- Active MRSA or communicable infections requiring isolation
- 24-hour skilled nursing needs
- Total ADL dependence with inability to communicate needs
A hospice waiver (HSC §1569.73) can allow continued care for residents on hospice who would otherwise fall into a prohibited category.
Ask on tour: Ask whether your loved one's specific care needs are restricted or prohibited, and what the facility's process is if needs change after admission.
How does CDSS enforce these rules?22 CCR §87755–87777 / HSC §1569.58
- 1Notice of DeficiencyWritten citation with a correction deadline. Facility must submit a Plan of Correction.
- 2Civil PenaltyStarts at $50/day for non-serious; $150/day for serious deficiencies — immediately, with no grace period. Repeats escalate to $150 first day + $50/day, then $1,000 first day + $100/day.
- 3Suspension of AdmissionsFacility cannot accept new residents until violations are corrected.
- 4Temporary Suspension or RevocationEmergency suspension for imminent danger; full revocation after administrative hearing.
- 5Exclusion OrderAdministrator and operator can be barred from all CDSS-licensed facilities — not just this one.
See how these rules have been applied to this specific facility:
View state inspection record and citationsState records
California Dept. of Social Services · Community Care Licensing- License number
- 415601137
- License type
- RESIDENTIAL CARE ELDERLY
- License status
- LICENSED
- License expires
- Not yet indexed
- Licensed beds
- 6
- Operator
- Sandhill Assisted Living Llc
Inspections & citations
21
reports on file
19
total deficiencies
16
Type A (actual harm)
1
dementia-care citations
Other visitJuly 10, 2025No deficiencies
Plain-language summary
An unannounced annual inspection on July 10, 2025 found the facility clean, well-maintained, and properly equipped with safety features including working smoke and carbon monoxide detectors, fire extinguishers, and secure storage for medications, sharps, and toxic materials. The home maintained appropriate room temperature, hot water temperature, and adequate food supplies, with complete medication records and up-to-date emergency drill logs. No deficiencies were cited.
View full inspector notes
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.
Other visitApril 10, 2025No deficiencies
Plain-language summary
On April 10, 2025, the state conducted an unannounced case-management visit to review the facility's hospice waiver increase. The inspector observed five residents and three caregivers on site and found no violations. No citations were issued.
View full inspector notes
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.
Other visitApril 10, 2025No deficiencies
Plain-language summary
On April 10, 2025, a state licensing analyst conducted an unannounced visit to deliver official documents related to a previous complaint investigation. The analyst met with the administrator and reviewed the findings with him. This was a routine administrative visit, not an inspection for violations.
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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.
ComplaintFebruary 19, 2025· SubstantiatedType A1 deficiency
Inspector: Grace Donato
Regulation
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...
Inspector finding
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.
Other visitAugust 22, 2024No deficiencies
Inspector: Grace Donato
Plain-language summary
A licensing analyst made an unannounced visit on August 22, 2024 to check on the facility's compliance after a previous meeting about violations involving residents' personal rights, staff records, emergency procedures, and incident reporting. The facility was found to be following reporting requirements and had current first aid training and emergency drills conducted with the local fire department in July 2024. No violations were cited during this visit.
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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.
Other visitAugust 22, 2024No deficiencies
Inspector: Grace Donato
Plain-language summary
On August 22, 2024, state licensing staff made an unannounced visit to monitor the facility's operations following a non-compliance conference held in October 2023 about reporting, dementia care, and staffing. Staff were observed providing daily living assistance to residents, dementia care training was current, incident reporting to the state was consistent, and staffing levels were adequate for current resident needs. No violations were found during this visit.
View full inspector notes
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.
Other visitAugust 1, 2024No deficiencies
Inspector: John Calandra
Plain-language summary
A state inspector visited on August 1, 2024, to verify that the facility had corrected a medication-related problem identified in a previous inspection on July 25, 2024. The facility had completed the corrections, and the deficiency was cleared. The inspector left a copy of the report with the administrator.
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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.
InspectionAugust 1, 2024Type B2 deficiencies
Inspector: John Calandra
Plain-language summary
During the facility's annual inspection in August 2024, inspectors found the building well-maintained with working smoke and carbon monoxide detectors, adequate food and supplies, and proper hot water temperatures. The facility received violations for not storing all food in covered containers, not recording hospice training sessions, having unscreened fireplaces, and not notifying licensing that exterior gates are locked. The administrator was informed of the violations and given information about appeal rights.
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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.
Regulation
(7) Fireplaces and open-faced heaters shall be adequately screened.
Inspector finding
Based on observation, the licensee did not comply with the section cited above in 2 out of 2 fire places which did not have screens, which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 08/09/2024 Plan of Correction 1 2 3 4 Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
Regulation
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (1) Licensees shall notify the licensing agency of their intention to lock exterior doors and/or perimeter fence gates.
Inspector finding
Based on observation and interview of the administrator, the licensee did not comply with the section cited above in 2 out of 2 fences which were observed to have locks on them and are locked according to the administrator, which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 08/09/2024 Plan of Correction 1 2 3 4 Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to…
Other visitJuly 25, 2024Type A2 deficiencies
Inspector: John Calandra
Plain-language summary
During a routine annual inspection on July 25, 2024, inspectors found that medications stored at the facility were not properly recorded in the facility's medication records, and the facility did not have backup supplies available in case of a power outage. Inspectors also noted that a key to the facility vehicle was not kept on site for emergencies. The facility has been directed to correct these issues.
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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.
Regulation
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
Inspector finding
Based on record review, the licensee did not comply with the section cited above in 4 out of 5 Centrally Stored Medication records(CSMR) which were missing a total of 12 medications,which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 07/26/2024 Plan of Correction 1 2 3 4 Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
Regulation
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, includi…
Inspector finding
Based on observation, the licensee did not comply with the section cited above in 1 out of 1 boxes of supplies that shall be available to provide alternative resources during an outage, which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 07/26/2024 Plan of Correction 1 2 3 4 Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
Other visitMay 24, 2024No deficiencies
Inspector: Grace Donato
Plain-language summary
On May 24, 2024, the state conducted an unannounced inspection to monitor the facility's operations following a non-compliance meeting held in October 2023. The inspection found that the facility had addressed the previous violations: residents' personal rights protections were in place, staff first aid training was current, emergency drills had been recently completed, and incident reporting was being done properly. No violations were found during this visit.
View full inspector notes
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.
ComplaintMarch 22, 2024No deficiencies
Inspector: Grace Donato
ComplaintFebruary 22, 2024· MixedType A2 deficiencies
Inspector: Grace Donato
Plain-language summary
An investigation of complaints found that staff could not provide information about a resident's bowel movements or maintain records of this care, which is required; however, a separate allegation about a power outage and hospice visit could not be substantiated with enough evidence. The facility was cited for not having adequate documentation and staff knowledge to meet residents' care needs.
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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. 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 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.
Regulation
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...
Inspector finding
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.
Regulation
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
Inspector finding
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.
Other visitFebruary 22, 2024Type A3 deficiencies
Inspector: Grace Donato
Plain-language summary
During an unannounced case management visit on February 22, 2024, inspectors found that the facility did not have enough food supplies for its current residents and that a newly admitted resident lacked required paperwork (though documentation was provided when requested). Staff were also not informed about the new resident's health conditions. The facility was cited for these deficiencies and notified that failure to correct them may result in penalties.
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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.
Regulation
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.
Inspector finding
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.
Regulation
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 ...
Inspector finding
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.
Regulation
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.
Inspector finding
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.
Other visitJanuary 16, 2024No deficiencies
Inspector: Grace Donato
Plain-language summary
On January 16, 2024, the state conducted a follow-up inspection to check whether the facility had corrected violations previously identified in a non-compliance meeting held in October 2023. The inspection found that the facility had updated first aid training, completed emergency drill training, removed dogs from the facility, and was properly reporting incidents as required.
View full inspector notes
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 Pers onal 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.
Other visitDecember 21, 2023No deficiencies
Inspector: Grace Donato
Plain-language summary
On December 21, 2023, state licensing staff made an unannounced visit to verify that a court-ordered exclusion of an individual from the facility was being followed. Staff confirmed the individual was no longer on the premises and found no issues during the facility tour.
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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.
Other visitNovember 6, 2023Type A1 deficiency
Inspector: Grace Donato
Plain-language summary
On November 6, 2023, licensing staff conducted a health check visit and found that the facility failed to report a resident's change in condition—a rash noted in a doctor's report—to the state as required. The facility was also found to have only one caregiver on staff at the time of the visit and received a recommendation to schedule two caregivers and ensure coverage when staff call out. The facility was cited for not following state reporting requirements and faces potential penalties if the violation is not corrected.
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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.
Regulation
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:
Inspector finding
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.
InspectionOctober 4, 2023No deficiencies
Inspector: Grace Donato
Plain-language summary
During a non-compliance meeting on October 4, 2023, inspectors found that the facility's dog bit a family member, two staff members had expired CPR certifications, personnel records were not readily available, emergency drill logs were incomplete, and a resident who fell multiple times was not reported to the licensing agency as required. The facility owners agreed to a compliance plan and will receive more frequent inspection visits over the next two years to ensure they meet state regulations.
View full inspector notes
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-providers
InspectionAugust 16, 2023Type A1 deficiency
Inspector: Murial Han
Plain-language summary
A dog bit a visitor on the facility grounds on August 10, 2023, causing bruising on both lower legs. An inspector's follow-up visit found that the dogs had escaped from the garage through a metal gate that wasn't fully closed, then ran out when a staff member opened a kitchen door. The facility was cited for this incident and must correct the gate closure procedures to prevent future escapes.
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On August 16, 2023, Licensing Analyst (LPA) Murial Han conducted an unannounced case management visit to follow up on an incident that was reported by the facility. LPA met with caregiver Susie Herrera and explained the purpose of the visit. On August 11, 2023, facility reported to CCL that a dog bit a visitor and this happened on August 10, 2023 at 7:15PM. Facility staff immediately removed the dogs and provided first aide care to the family member which revealed no bleeding but bruising were noted on both lower legs. During today's case management visit, LPA conducted facility tour, interviewed resident, facility staff, and reviewed records. According to facility staff, the dogs stay in the garage and the garage is connected to the kitchen that is connected to the rest of the facility. To prevent the dogs from entering the kitchen, there is mental gate in front of the garage door and the kitchen and to prevent the dogs from leaving the kitchen and there is a sliding door that should remained closed at all times. On the day of the incident, staff #1 (S1) was in the kitchen and both dogs managed to get out of the garage and entered the kitchen as the mental gate was not closed all the way. When staff #2 (S2) gently open the kitchen door to show a family member of a call pendant device in the kitchen, both dogs ran out from the kitchen and one of them bit the family member. 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 Facility staff acknowledged that the mental gate should've been closed all the way to prevent these situation from happening. Deficient is cited under California Health and Safety Code on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed and reviewed with caregiver; Findings were discussed with administrator over the phone. A copy of this report and the Appeal Rights is provided.
Regulation
87468.1 Personal Rights of Residents in All Facilities..a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful..
Inspector finding
The requirement is not met as evidenced by facility dog presented aggression toward a family member and bit the family member which posed an immediately health risk for resident in care.
Other visitJuly 24, 2023Type A7 deficiencies
Inspector: Grace Donato
Plain-language summary
An unannounced annual inspection found the facility clean and well-maintained with adequate food, linens, and supplies, but identified several documentation issues: two staff members lacked current CPR and First Aid training, some resident admission and assessment forms were missing required administrator signatures, and the facility had not conducted required emergency disaster drills. The facility was directed to correct these deficiencies and submit updated records.
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LPA Grace Donato conducted an unannounced annual visit to the facility. LPA met with caregiver Susie Herrera. LPA toured the facility inside and outside with the caregiver. While touring the facility it was observed that the room temperature was at 78 deg F. Hot water was also tested and temperature was 110 deg F. Each resident rooms were checked. The residents have adequate amount of linens and incontinence care items. Adequate lighting is available in all rooms. All personal belongings are intact. All residents are comfortable and taken care of. Carbon monoxide monitor is working properly. All fire extinguishers have been checked. Bathrooms were observed to be in good repair equipped with non-skid mats and grab bars. There is also adequate amount of food. 2 days for perishables and & 7 days non-perishable. Medication review was done for all residents and all medications are accounted for and centrally stored medication records are updated. 3 staff records available in the facility were reviewed . All staff records reviewed has criminal record clearance and are associated with the facility. Based on record reviews, it was noted that 2 the facility staff does not have updated CPR & First Aid training. Personnel records are not maintained in the facility resulting for some documents being unavailable when needed. Resident records were checked. 2 out 3 doesn’t have signature of Licensee/Administrator in the admission agreement. One resident doesn’t have signature on LIC 603 (Needs & Appraisals), another resident doesn’t have signature on LIC 621 (Personal Property & Valuables). Licensee/Administrator was advised to have these records signed. All records that still have the Orchid Lan name should be updated to Sandhill Assisted Living. 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 Staff are scheduled either up until 7 pm or 10 pm. Administrator confirmed on phone that live-in staff take care of residents needing assistance after shift and is compensated for work done during that time. Facility doesn't have a record of Emergency Disaster drill log. LPA advised administrator that drill shall be completed quarterly. LPA requested licensee to submit the following and was received by 7/24/2023: LIC 308 Designation of Facility Responsibility LIC 500 Personnel Report Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with caregiver and a copy is provided with appeal rights.
Regulation
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after …
Inspector finding
Based on 2 Personnel Files are not on file in the facility and is not readily available for checking which poses an immediate health and safety risk to residents.. POC Due Date: 07/25/2023 Plan of Correction 1 2 3 4 Submit plan of action to ensure that files are readily to available for checking. Make the files available in the facility.
Regulation
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require sta…
Inspector finding
Based on record review, the licensee did not comply with the section cited above because 2 staff members doesn't have valid CPR training which poses an immediate health and safety risk to residents or personal rights risk to persons in care. POC Due Date: 07/25/2023 Plan of Correction 1 2 3 4 Submit a plan on how the 2 staff members will get the training required.
Regulation
(g) All personnel records shall be maintained at the facility.
Inspector finding
Based on record review 2 personnel records were not readily available in the facility which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 07/25/2023 Plan of Correction 1 2 3 4 Submit a plan on how to make staff records readily available in the facility.
Regulation
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
Inspector finding
Based on record review 2 personnel records were not readily available in the facility which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 07/25/2023 Plan of Correction 1 2 3 4 Submit plan of action to ensure that files are readily to available for checking. Make the files available in the facility.
Regulation
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill,…
Inspector finding
Based interview no emergency drill logs are available in the facility. Drills in the facility were done every 6 months instead of quarterly which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 07/25/2023 Plan of Correction 1 2 3 4 Submit a plan on action on when this drills are going to be scheduled and ensure that staff sign for the in service training.
Regulation
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as…
Inspector finding
Based on record review, the licensee did not comply with the section cited above due to 2 out 3 doesn’t have signature of Licensee/Administrator in the admission agreement. One resident doesn’t have signature on LIC 603 (Needs & Appraisals), another resident doesn’t have signature on LIC 621 (Personal Property & Valuables) which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 07/28/2023 Plan of Correction 1 2 3 4 Have all necessary documents si…
Regulation
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. …
Inspector finding
Based Deficient Practice Statement 1 2 3 4 Based on interview, a resident mentioned that he/she fell several times. No report was submitted to licnesing. The licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 07/25/2023 Plan of Correction 1 2 3 4 Provide a plan of action as to how to address incident reports.
Other visitJune 28, 2022No deficiencies
Inspector: Komal Charitra
Plain-language summary
This was a pre-licensing inspection conducted on June 28, 2022, following a change of ownership. The inspector found the facility to be clean and well-maintained, with proper safety features including working smoke and carbon monoxide detectors, secure storage of medications and chemicals, appropriate water temperatures, and adequate emergency equipment and signage throughout.
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On June 28, 2022 at 10:45AM, Licensing Program Analyst (LPA) Komal Charitra met with Administrator/Licensee Susan Somporn to conduct an announced Pre-Licensing inspection for a change of ownership. LPA Charitra was properly screened for COVID-19 at entry point. LPA observed the indoor and the outdoor passageways are free of obstruction. The Administrator provided a tour of the facility. This is a single story facility with 7 bedrooms (5 resident rooms and 2 staff room) and 4 bathrooms. There were 3 residents and one staff present during the visit. 3 resident rooms are occupied; all are private. One bedroom was observed to be shared room with beds 6ft apart. All bathrooms were observed to be equipped with grab bars, non-skid mats, hand washing signage, liquid soap, paper towels, and a covered trash can. The facility is observed to be spacious, clean, and odor-free. There was good lighting and the facility was measured at 69 degrees Fahrenheit (F). The living room and the dining room is observed to be comfortable, spacious with adequate furniture. The activities calendar is posted in the living room. The outdoor space is spacious. Emergency exiting plans are posted. LPA observed COVID-19 signs through-out the facility and social distancing stickers are posted on the floors. The hot water temperature was measured in the 4 bathrooms, showers and the kitchen were at 105- 110 degrees F. LPA observed toxins, chemicals, disinfectants to be locked and inaccessible to the residents. There are sufficient lighting in the hallways. Night lights are present in hallways and bedrooms. CONT. to 809C 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 toured the kitchen. LPA observed the locked medication cabinet and the locked cabinet with sharps. The refrigerator temperature was measured at 38 degrees F and the freezer was measured at 0- (-1) degree F. LPA observed 2 day perishable and 7 day non-perishable present. The Carbon Monoxide detectors were present and properly operated. The fire and smoke detectors are observed in every room and observed to be operated properly, the fire extinguishers observed to be adequate. The first aid kit was observed to be present and completed. Extra linen was available. The Administrator reported that there is no firearms at the facility. LPA toured the garage which is locked at all times. Washer and dryer were observed to be in good working condition. The Personal Policy Procedures, Facility Floor Plan, Emergency Disaster Plan, Labor Law and Ombudsman postings are posted by the main entrance. 30- day PPE supplies are present at the facility. There were no objects obstructing the emergency shut-offs: water, electricity (all locations are labeled) and gas shut-off stations. Facility sketch accurately reflects the floor plan. Report is reviewed with Administrator/Licensee and a copy is provided.
ComplaintJune 2, 2022No deficiencies
Inspector: Bailey Humes
Plain-language summary
This was a pre-licensing inspection where the state verified that the facility's administrator and applicant understood California regulations for operating a memory care home for up to 6 residents. The administrator demonstrated knowledge of licensing requirements, staffing rules, admission policies, emergency procedures, and complaint reporting during a telephone interview. No violations were identified.
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Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 3 COMP II Participants: Tilma, Susan (Administrator and Corporate Board Member)Interview Method: Telephone interview On 6/2/2022, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readiness
Federal summary
CMS Care CompareNot a CMS-certified facility
California RCFEs (residential care facilities for the elderly) are licensed by the state, not by CMS. CMS data only applies to skilled nursing facilities or to CCRCs that operate a licensed SNF wing.
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