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.
1239 Middle Ave · 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
Severity32thWeighted citations per bed
Repeats100thRepeat deficiencies as share of total
Frequency71thDeficiencies 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 B−. Better than 68% of comparable California RESIDENTIAL CARE ELDERLY facilities. Severity: 32th percentile. Repeats: top 0%. Frequency: 71th 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
stableWeighted severity score per month · 24 months
Weighted score (24mo)
3
Last citation
Nov 24
Finding distribution
7 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 Sep 202322 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 Sep 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
- 415601141
- License type
- RESIDENTIAL CARE ELDERLY
- License status
- LICENSED
- License expires
- Not yet indexed
- Licensed beds
- 6
- Operator
- Sandhill Assisted Living Llc
Inspections & citations
15
reports on file
8
total deficiencies
6
Type A (actual harm)
3
dementia-care citations
Other visitOctober 30, 2025No deficiencies
Plain-language summary
During an unannounced annual inspection on October 30, 2025, inspectors found the facility clean and well-maintained, with secure storage of medications and chemicals, working safety equipment, and complete resident and staff records. All required furnishings, bathrooms, first aid supplies, and emergency procedures were in place and up to date. No violations were cited.
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On October 30, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced annual inspection. LPA met with Co-Administrator, Ricardo Aban and explained the purpose of the visit. LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageway was free of obstruction. No accessible bodies of water of fire safety hazards observed. This is a single story facility. There are six resident rooms all of which are private rooms. Resident rooms were observed to be clean with all required furniture. LPA observed 3 staff rooms. LPA observed 4 full bathrooms. Bathrooms were observed to be clean, odor-free and in good repair. Water temperature throughout the facility measured between 116-118 degrees F. Extra linen was observed to be present. First aid kit was observed to be complete. Dining room was observed free from tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. LPA observed two day perishables and seven day non-perishables. Medications, sharps, and chemicals were observed locked an inaccessible to residents in care. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of April 2025. Emergency drills are logged and done every three month. LPA reviewed 5 resident records and 5 staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. No citations are issued during the visit. Report is reviewed with Co-Administrator and a copy is provided.
InspectionApril 10, 2025No deficiencies
Plain-language summary
On April 10, 2025, a licensing analyst made an unannounced visit to deliver updated regulatory paperwork related to a previous complaint investigation. The administrator met with the analyst to review the documentation. No violations were identified during this visit.
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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-20250129105003 Report is reviewed with Administrator, Ricardo Aban and a copy is provided.
Other visitNovember 4, 2024Type B1 deficiency
Inspector: Grace Donato
Plain-language summary
This was a routine annual inspection on November 4, 2024, where the facility was found to be clean, well-maintained, and properly equipped with safety features like grab bars, working smoke detectors, and current fire extinguishers. The inspector found that the facility's admission agreement contained a clause denying refunds for residents in respite or hospice care, which does not comply with California regulations, and the facility was cited for this violation. The facility was also noted to be in compliance with hospice care requirements and to maintain adequate food supplies and conduct required emergency drills.
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On 11/4/2024, LPA Grace Donato made an unannounced annual visit to the facility. LPA met Co-Administrator Ricardo Aban. LPA explained the purpose of the visit. LPA toured the facility inside and outside including all of resident rooms, common areas, kitchen area & garage. The indoor and outdoor passageways were free of obstruction. While touring the facility it was observed that the room temperature was at 69 deg F. Hot water was also tested in the bathrooms and the temperature was 110 deg F. Carbon monoxide monitor are working properly. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid mats. All personal belongings of residents are intact. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every quarter. Five resident records and four staff records were reviewed. Staff records are complete, with training logs. Facility accepts hospice residents and are in compliance with the required waiver requirements. LPA requested the following documents: LIC 308, Control of Property, Certificate of Liability Insurance, LIC 500, LIC610E. Upon reviewing resident records it was found out that three out of five residents have a clause in their admission agreement about refunds. Clause states that "Residents on Respite Care and or Hospice Care: No refunds are offered due to uncertainty length of stay and of resident's condition." The facility’s admission agreement does not meet Title 22, Div. 6, Chapt. 8, Article 9, Sec. 87507 Admission Agreements. Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed and copy of report and appeal rights are provided.
Inspector finding
Based on records review, the licensee did not comply with the section cited above due R1, R2, R3s admission agreements have a clause regarding not providing refund of fees upon death, which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 11/11/2024 Plan of Correction 1 2 3 4 Facility administrator to submit a plan of action to licensing by 11/11/2024 to describe how facility plans to provide the refund per regulations or as required to family me…
Other visitMay 24, 2024No deficiencies
Inspector: Grace Donato
Plain-language summary
During an unannounced inspection on May 24, 2024, inspectors monitored the facility's operations following previous violations related to reporting, dementia care training, and staffing levels. The facility was found to be in compliance: staff are providing appropriate care activities for residents, dementia care training is current, incident reporting to the state is consistent, and staffing levels are adequate for current resident needs. No violations were cited.
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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 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 some residents. 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 with Administrator and a copy is provided.
Other visitFebruary 23, 2024Type A1 deficiency
Inspector: Grace Donato
Plain-language summary
This was an unannounced inspection on February 23, 2024, to check on violations that had been identified at a previous meeting in October 2023 regarding reporting practices, care of residents with dementia, and staffing. The facility was found to be meeting reporting requirements and staff had received training on dementia care, but inspectors found the facility did not have enough non-perishable food on hand to cover seven days for its current six residents, which is a violation of state regulations. The facility was told that failure to correct this food supply deficiency could result in civil penalties.
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On 2/23/24, Licensing Program Analyst (LPA), Grace Donato conducted an unannounced case management- legal/non-compliance inspection to monitor the facility operation. LPA met with Caregiver Jonathan Mendoza and Administrator Ricardo Aban followed after. LPA 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, Administrator discussed the staff training with regards to Care of Persons with Dementia received from Redwood Hospice. Facility is still up to date regarding reporting requirements, staff has been constantly reporting incidents and then submitted to Licensing. No need for night shift at the moment but will be addressed by Licensee if needed. LPA toured the facility, and it was observed there is not enough food supply when the current census is six. Non-perishable food is not enough 7 days. Deficiency is being 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
87555 General Food Service Requirements (b) The following food service requirements shall apply: (26)Supplies 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
A state inspector conducted an unannounced follow-up visit on January 16, 2024, to check on the facility's progress after a previous non-compliance meeting in October 2023 that had identified issues with reporting, dementia care, and staffing. The facility was found to be compliant: staff had received dementia care training, incident reporting was current, and staffing levels were adequate for the residents. No violations were identified during this visit.
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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 Reporting Requirements, Care of Persons with Dementia , Personnel Requirements. During LPAs visit, Administrator discussed the staff training with regards to Care of Persons with Dementia received from Redwood Hospice. Facility is still up to date regarding 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 with Administrator and a copy is provided.
Other visitDecember 21, 2023No deficiencies
Inspector: Grace Donato
Plain-language summary
On December 21, 2023, inspectors made an unannounced visit to verify that a previously ordered exclusion of an individual from the facility had been carried out. The inspector confirmed that the individual was no longer at the facility and that all requirements had been met.
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On 12/21/23 Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management visit. LPA met with Administrator Ricardo Aban 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.
InspectionOctober 4, 2023No deficiencies
Inspector: Grace Donato
Plain-language summary
During a follow-up meeting on October 4, 2023, regulators discussed violations including a resident with dementia who had eloped twice—the second time through an unsecured fence—and inadequate staffing to prevent this. The facility was ordered to implement a compliance plan and will receive more frequent inspections over the next two years to ensure it meets state regulations.
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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, Reporting Requirements for a change in condition of a resident and elopement, Care of Persons with Dementia for R1 eloping for the second time, not having awake staff, R1 able to leave through perimeter fence unassisted. In addition, during the non-compliance meeting, LPM & LPA delivered an amended deficiencies from a citations on 8/8/2023. 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
Other visitSeptember 18, 2023Type A1 deficiency
Inspector: Grace Donato
Plain-language summary
On September 18, 2023, an inspector made an unannounced annual visit and found the facility in good condition overall, with proper temperature control, working safety equipment, adequate food and medication storage, and well-maintained resident rooms. However, the inspector found that the facility failed to report a resident's emergency room visit as required, and was cited for this violation and assessed a $250 penalty for a repeat failure to report incidents. The facility was asked to correct this reporting requirement.
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On 9/18/23 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Caregiver Jonathan Mendoza. LPA explained the purpose of the visit. LPA toured the facility inside and outside including all of resident rooms, common areas, kitchen area & garage. The indoor and outdoor passageways were free of obstruction. At around 11:30 am, the residents were observed to have lunch in dining area.. While touring the facility it was observed that the room temperature was at 71 deg F. Hot water was also tested in the bathrooms and the temperature was 108 deg F. Carbon monoxide monitor are working properly. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid mats. All personal belongings of residents are intact. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every quarter. Two resident records and two staff records were reviewed. Staff records are complete, with training logs. Facility accepts hospice residents and are in compliance with the required waiver requirements. LPA interviewed two residents and one staff member. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. LPA requested the following documents: Control of Property, Certificate of Liability Insurance, LIC 500. Upon reviewing resident records it was found out that an incident wasn't reported to CCLD. A resident (R1) was sent to ER and no incident report was done or sent to CCLD. 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 A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $250 for repeat violation regarding reporting requirements. Please see LIC421FC. This report was reviewed with and a copy of the report and appeal rights was 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.
Inspector finding
Based on record reviews and interviews, the licensee did not comply with the section cited above due incident not being reported to CCLD which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 09/19/2023 Plan of Correction 1 2 3 4 Licensee to submit a plan in order to address reporting requirements to CCLD. Licensee to submit plan by POC due date.
Other visitSeptember 1, 2023Type A2 deficiencies
Inspector: Grace Donato
Plain-language summary
During an unannounced visit on September 1, 2023, inspectors found that a resident with wandering behavior had eloped from the facility early on August 27th and was returned by police about an hour later without injury. The facility was cited for not having adequate safeguards to prevent residents from leaving without assistance, for failing to reassess the resident after the elopement to determine if additional care was needed, and for having no staff on duty at night despite knowing this resident had a history of wandering.
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On 9/1/2023, Licensing Program Analyst (LPS) Grace Donato conducted an unannounced case management visit. LPA met with Caregiver, Jonathan Mendoza. LPA explained the purpose of the visit. LPA received an incident report last 8/29/23 regarding a resident (R1) eloping from the facility. The incident happened on 8/27/23, R1 eloped from the facility around 1am and was returned by Police around 2 am with no injuries. Staff (S1) that currently resides on the facility, but not on shift, did not hear the alarm went off around that time. While LPA was in the facility, R1 was currently having lunch in the dining area. LPA observed that all exit points have a loud alarm when door is opened. Facility also has a main gate which is open the whole day and closed during nighttime. It is unknown which gate R1 used to exit the facility premises. LPA spoke with Licensee, Diana Covich on the phone. There was no reassessment done for R1 after the elopement. Licensee has scheduled a reassessment for the resident.There is no night supervision scheduled in the facility. Based on document review, R1 has wandering behavior. Deficiencies are cited today as the facility did not ensure that residents won’t be able to leave the facility without assistance. Facility also didn’t make sure that R1 had a reassessment after the incident, this is to address any additional care that might be needed. Facility is also being cited for not having night supervision available even when there is a resident who have wandering behavior. 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
87705 (c)Licensees who accept and retain residents with dementia...(5)Each resident with dementia shall have an annual medical assessment... (A) When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed... This requirement was not met as evidenced by:
Inspector finding
Based on record reviews and interviews, the licensee did not comply with the section cited above due to R1 not being reassesed after the elopement which poses an immediate health, safety or personal rights risk to persons in care.
Regulation
87705(c) Licensees who accept and retain residents with dementia...(4)There is an adequate number of direct care staff...(A)In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents... This requirement was not met as evidenced by:
Inspector finding
Based on record reviews and interviews, the licensee did not comply with the section cited above due to R1 having wandering behaviors but Licensee did not schedule nigh supervision which poses an immediate health, safety or personal rights risk to persons in care.
Other visitAugust 8, 2023Type A2 deficiencies
Inspector: Grace Donato
Plain-language summary
During an unannounced visit on August 8, 2023, inspectors found that a resident with dementia left the facility unsupervised through an open gate and was able to walk away unaccompanied; the facility also failed to report this elopement incident to licensing authorities in a timely manner. An allegation that a caregiver had ripped a resident's clothes could not be confirmed because that resident had since passed away. The facility was cited for inadequate supervision and failure to report the elopement as required.
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On 8/8/2023, Licensing Program Analyst (LPS) Grace Donato conducted an unannounced case management visit. LPA met with Licensee, Susan Tilma. LPA explained the pruspose of the visit. LPA received information regarding concerns about male caregiver (S1) “ripping clothes” of a female resident (R1). Another report regarding a resident (R2) eloping on 6/27/23. On the concern about a S1 “ripping clothes” of R1, based on interviews, it cannot be confirmed that said incident happened due to R1 passing. R1 has been on hospice and has dementia. With regards to R2 eloping, no record of the incident was reported to the facility. Based on interviews, Licensee mentioned that they weren't able to report the incident to CCLD. R2 likes walking around the facility. R2 was able to exit on one of the gates. On the day mentioned, R2 was able to go out unsupervised. Based on record reviews, resident has dementia and should not be able to leave the facility without supervision. Deficiencies are cited today as the facility did not ensure the elopement incident was reported on a timely manner to CCLD. Also, the facility staff wasn't able to supervise the R2 while going around the facility leading him to leave unaccompanied/unsupervised. 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
Amended 87705(h)Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.This requirement was not met as evidenced by:
Inspector finding
Based on ord reviews and interviews, the licensee did not comply with the section cited above due resident with dementia being able to leave facility unassited which poses an immediate health, safety or personal rights risk to persons in care.
Regulation
Amended to Type A 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 was not met as evidenced by:
Inspector finding
Based on record reviews and interviews, the licensee did not comply with the section cited above due incidents not being reported to CCLD which poses an immediate health, safety or personal rights risk to persons in care.
Other visitNovember 16, 2022No deficiencies
Inspector: Murial Han
Plain-language summary
This was a follow-up pre-licensing inspection on November 16, 2022, where staff showed the inspector the facility and confirmed that safety concerns from an earlier inspection had been fixed—medications and chemicals were properly locked up, the first-aid kit was complete, and water temperatures in bathrooms were safe. The inspector found no remaining problems and recommended the facility be approved for immediate licensure.
View full inspector notes
On 11/16/2022, Licensing Program Analyst (LPA) Murial Han conducted a follow-up pre-licensing inspection from the initial pre-licensing that was done on 10/25/2022. LPA met with lead staff, Averelle Aban and the administrator, Susan Tilma arrived shortly thereafter to complete the inspection. During today's inspection, lead staff provided a tour of the facility and LPA inspected the area of concerns that were identified during the initial inspection. LPA observed the medication, and the chemical/toxins were appropriate stored, locked and inaccessible to residents. The first-aid kit is inspected and complete. The kitchen sink, the bath/shower rooms water temperature were measured at 105.1 to 105.8 degrees Fahrenheit (F). As a result of today's inspection, the area of concerns from the initial inspection have been resolved. Pre-Licensing is now complete. Immediate Licensure is recommended pending final approval from the Central Applications Bureau. Comp III orientation was given to the Administrator, Susan Tilma and Lead Staff, Averelle Aban. This report is reviewed and discussed with the administrator. A copy of the report is provided.
Other visitOctober 25, 2022No deficiencies
Inspector: Murial Han
Plain-language summary
On October 25, 2022, state inspectors conducted an unannounced pre-licensing inspection of this facility and found it generally clean and well-maintained, but identified four items that needed to be fixed before the facility could be licensed: medications and cleaning chemicals were not locked up, there was no first aid kit on hand, and staff did not have a thermometer to check hot water temperature. The administrator was notified of these deficiencies and told to address them before a follow-up inspection.
View full inspector notes
On 10/25/2022, Licensing Program Analyst (LPA), Murial Han met with the Administrator, Susan Tilma and conducted an unannounced Pre-Licensing inspection. LPA observed the indoor and the outdoor passageways are free of obstruction. LPA toured facility and grounds. This is a single level facility. The facility has 6 private resident rooms, 3 staff rooms, 2 resident bathrooms, 1 visitor bathroom and 1 staff bathroom. There is 5 residents during the time of the inspection. LPA observed good lighting and comfortable temperature in the facility. The living room and the dining room is observed to be comfortable, spacious with adequate furniture. LPA observed sufficient hygiene and cleaning supplies. The refrigerator was measured at 35 degrees Fahrenheit (F) and the freezer was measured at 0 degrees F. Dry goods/emergency food supplies are stored in the garage.. LPA observed COVID-19 signs posted by the entrance, within the facility, hand washing instruction signs by the hand washing stations and other postings such as the Licensing Complaint Poster, Resident Rights, etc. Pre-Licensing is incomplete during this inspection due to the following observations: - Medication is stored at a centralized area, however, it was not properly locked - Chemicals, disinfectants, cleaning solutions, etc. are not properly locked - Facility did not have a first aid kit - The facility did not have a thermometer to measure the hot water temperature 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 The administrator acknowledged the above findings and LPA recommended the facility to review the pre-licensing checklist prior to the follow-up inspection. Deficiencies for today's findings will be cited under facility Orchid Villa Residential Home, facility # 410508820. Exit interview conducted with administrator. A copy of this report is provided
InspectionOctober 25, 2022Type B1 deficiency
Inspector: Murial Han
Plain-language summary
During a pre-licensing inspection on October 25, 2022, the facility was found to have clean, comfortable living spaces with proper food storage temperatures, but four safety issues were identified: medications and chemical cleaning supplies were not properly locked, a first aid kit was missing, and there was no thermometer to measure hot water temperature. The administrator acknowledged these findings and was instructed to address them before the follow-up inspection.
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On 10/25/2022, Licensing Program Analyst (LPA), Murial Han met with the Administrator, Susan Tilma and conducted an unannounced Pre-Licensing inspection. LPA observed the indoor and the outdoor passageways are free of obstruction. LPA toured facility and grounds. This is a single level facility. The facility has 6 private resident rooms, 3 staff rooms, 2 resident bathrooms, 1 visitor bathroom and 1 staff bathroom. There is 5 residents during the time of the inspection. LPA observed good lighting and comfortable temperature in the facility. The living room and the dining room is observed to be comfortable, spacious with adequate furniture. LPA observed sufficient hygiene and cleaning supplies. The refrigerator was measured at 35 degrees Fahrenheit (F) and the freezer was measured at 0 degrees F. Dry goods/emergency food supplies are stored in the garage.. LPA observed COVID-19 signs posted by the entrance, within the facility, hand washing instruction signs by the hand washing stations and other postings such as the Licensing Complaint Poster, Resident Rights, etc. Pre-Licensing is incomplete during this inspection due to the following observations: - Medication is stored at a centralized area, however, it was not properly locked - Chemicals, disinfectants, cleaning solutions, etc. are not properly locked - Facility did not have a first aid kit - The facility did not have a thermometer to measure the hot water temperature The administrator acknowledged the above findings and LPA recommended the facility to review the pre-licensing checklist prior to the follow-up inspection. Deficiencies for today's findings will be cited under facility Orchid Villa Residential Home, facility # 410508820. Exit interview conducted with administrator. A copy of this report 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 The administrator acknowledged the above findings and LPA recommended the facility to review the pre-licensing checklist prior to the follow-up inspection. Deficiencies for today's findings will be cited under facility Orchid Villa Residential Home, facility # 410508820. Exit interview conducted with administrator. A copy of this report is provided.
Regulation
87465 Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed by each facility...8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available....
Inspector finding
This requirment is not met as evicenced by: the facility did not have a first aid kit for LPA to inspect during the pre-licensing inpsection which poses a potential health risk to residents in care.
ComplaintSeptember 29, 2022No deficiencies
Inspector: Celia Phomphachanh
Plain-language summary
This was a compliance review for a change in ownership at a 6-bed residential care facility for elderly people. The facility's corporate board member was interviewed by phone and confirmed understanding of California regulations covering facility operations, admission policies, staffing, health conditions, emergency preparedness, and complaint procedures. The facility passed this review.
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Component II completion: Successful Facility Type: Residential Care Facility for Elderly (RCFE) Application Type: Change in Ownership (CHOW) Capacity: 6 Census (if any clients in care): 5 COMP II Participants: Diana Covich, Corporate Board Member Interview Method: Telephone interview On September 29, 2022 at 10:00 AM, Applicant participated in COMP II. Identification of the Applicant was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant confirmed the understanding of the California Code Title 22 Regulations. During COMP II, CAB Analyst confirmed Applicant's nderstanding of following areas: 1. Facility Operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing Requirements/CPMB associations & Training 4. Restrictive/Prohibited Health Conditions 5. General Provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing Readiness Exit interview conducted with Corporate Board Member. Copy of report will be sent via email PDF to Administrator and Corporate Board Member and informed to return signed copy by end of business day today.
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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