Silver Oaks

On March 12, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced pre-licensing inspection visit. LPA met with Acting Administrator, Nick Catalano and explained the purpose of today's visit. Pre licensing inspection conducted. Report is reviewed with Nick Catalano and a copy is provided.

On January 30, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit. LPA met with Acting Administrator, Nick Catalano and explained the purpose of the visit. During the visit, LPA delivered a copy of amended LIC9099 for a complaint report that was initially issued on January 8, 2026. Report was reviewed with Acting Administrator, Nick Catalano and a copy is provided.

On December 10, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit in relation to an incident that occurred on 11/20/25. LPA met with Resident Care Coordinator, Rose Ruiz and explained the purpose of the visit. The Licensee reported on 11/20/25, Resident 1 (R1) bit into a bar of hand soap. Caregivers assisted in washing it out and giving R1 water. R1's lip was swollen. Poison control was contacted and R1's responsible party and physician was notified. R1 was in the communal area for observation. During the visit, LPA reviewed R1's file and discussed the incident with Resident Care Coordinator. According to the Resident Care Coordinator, R1 has a roommate, Resident 2 (R2) who's family member brought in the bar soap and placed it in R2's cubby without notifying staff. According to R1's file reviewed, R1's physician's reports dated 3/5/25 indicates that R1 has a dementia diagnosis, however is not at risk if allowed direct access to personal grooming and hygiene items. According to R2's physician's report dated 10/3/25, R2 has a dementia diagnosis and is at risk if allowed direct access to personal grooming and hygiene items. Resident Care Coordinator indicated that R2's responsible party was informed about the incident and was notified that if chemicals/hygiene products are being brought into the facility, it needs to be locked in the storage room by staff. Based on records reviewed, this is the first time R1 has shown at risk behaviors if he/she has access to personal grooming items and hygiene items. R1's service plan was updated to show R1 is at risk if allowed access to hygiene items. No citations are being issued during the visit. Report is reviewed with Resident Care Coordinator, Rose Ruiz and a copy is provided.

Based on the third party radiology company interviewed, they never went to the facility on 6/30/25. The third party radiology company called the facility on 6/30/25 to schedule an appointment for 7/1/25, however were told by facility staff that R1 no longer resided at the facility. Radiology company called the physician's office to confirm and eventually did go out to the facility and do chest x-rays for R1 on 7/1/25. Based on documents reviewed, it was observed that the facility only faxed the physician's office on 6/29/25 and called the after-hour supportive care service number on 7/1/25 and received confirmation from the physician's office indicating that the fax was received. According to the administrator, the med-techs only have access to the phones so if someone called to schedule an appointment for a resident, the med-techs and/or the directors would be aware of it. Based on interviews with the med-techs that were on shift 6/30/25 and 7/1/25, it was indicated that no agency called to schedule an appointment for R1 and that all med-techs are aware of R1 and who he/she is. In addition, they indicated that only med-techs have access to the phone so if someone did call to schedule an appointment for R1, they would be aware. Therefore, based on interviews conducted and record reviewed, the department has determined that although the above allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed with the Dietary Supervisor, Francis Macahilas and a copy is provided.

In addition, staff interviewed indicated that COVID positive residents would be provided meals in their rooms and if they did wander in the facility, staff would redirect them back to their room. During the time of the COVID outbreak, the administrator indicated that all staff members were required to wear masks and high touched surfaces were being cleaned once or twice a shift. Based on documentation reviewed, the facility followed their COVID-19 mitigation plan. Regarding the allegation, staff do not meet resident needs, according to the reporting party, facility does not have enough staff on the floor, as there was one day with only 2 caregivers for 40 residents and during the night, there is only one caregiver. During the investigation, LPA observed 5 caregivers present at the facility and 1 med-tech. According to the administrator and the sales director, the facility is fully staffed and there has not been any issues with staffing. In addition, according to 4/5 staff members interviewed, there is no issues with staffing at the facility, and they believe that they are able to manage with the amount of caregivers there are. Furthermore, the administrator and 4/5 staff interviewed indicated that there are 4-5 caregivers and 1 med-tech during the AM shift, 4-5 caregivers and 1 med-tech during the PM shift, and 2 caregivers and 1 med-tech during NOC shift. Therefore, based on interviews conducted, information collected and observations, the department has determined that although the above allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations, staff do not ensure residents have incontinence supplies, staff did not follow protocols to prevent the spread of COVID, and staff do not meet resident needs is UNSUBSTANTIATED. Report is reviewed with the administrator and a copy is provided.

On 7/5/2024, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Resident Care Coordinator Natalie Archer and explained the purpose of the visit. LPA toured the facility inside and outside including a random sample of resident rooms, common areas, and kitchen area. LPA observed most residents engaged in different activities. While touring the facility it was observed that the temperature was at 71 deg F. Hot water was also tested in the resident rooms and the temperature was 112 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Facility has sprinkler system. 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 floors. 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 five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic 20hr requirement. Facility has a certified administrator on site with complete certification and training requirements. Facility accepts hospice residents and are in compliance with the required waiver requirements. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. LPA requested the following documents: LIC500 Personnel Report, Liability Insurance. No deficiencies are cited at this time. Report is reviewed with Administrator and a copy is provided.

Regarding the allegation of staff are not meeting resident’s needs, RP stated that he/she has noticed that the staff don’t spend time with the residents. RP stated that the staff are on their phones a lot and talking to each other a lot instead of giving the residents some attention as some of them are depressed. RP stated that this has been happening for the last six months. The five responsible parties that were interviewed mentioned that they don’t have problems with the care that their residents receive. F2 stated that there is no issue with care as they do a good job. LPA also observed during the visit on 03/07/24, that the phones of staff members were surrendered to Resident Care Coordinators office during shifts. No staff have mobile phones on the floor. Staff were also assisting residents during this time. There was an activity happening in the activity room. Staff interact with residents if they need anything or just check and chat with them. Therefore, based on interviews and observations, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided.

Based on record reviews, there were several incident reports submitted by facility to Licensing documenting discoloration of skin on R1 . Along with these reports are witness accounts where R1 was rough handled by a visitor . R1s recent needs and services plan includes full assistance due to R1 being combative and fighting staff when being aided with activities of daily living. Staff were also trained and re-trained for Patient Transfer and Activities of Daily Living. R1s medication list was reviewed and none of it may cause the resident to easily bruise. Therefore, based on interviews & records review, 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. Report is reviewed and copy is provided.

Based on records review, four staff records were checked and all SOC341A Mandatory Reporting forms were signed. Therefore, based on the interviews conducted, files reviewed, and information collected, the allegation mentioned is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The report was reviewed, and a copy is provided.

On 4/18/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management incident visit.. LPA met with Executive Director, Joshua Lambengco and Resident Care Coordinator, Bernadette Kang and explained the purpose of today's visit. On 2/12/2024, Licensing received a report of resident (R1) who died due to choking. LPA investigated and interviewed staff. Staff member (S1) mentioned that R1 was having snacks during that time and was seated on the bed while being fed. R1 was fine eating until R1 stopped talking. R1 then signaled pointing to his/her throat. S1 immediately called for help and emergency services were called. Police and 911 arrived and took over. Based on record reviews, R1 is non ambulatory, no assistance with meal reminders or feeding support. R1 also has a Physician Orders for Life-Sustaining Treatment (POLST) order of Do Not Resuscitate. Staff has updated training for first Aid. A police report was obtained and stated that emergency services were instructing the staff to take out food items from R1s mouth. No deficiencies being cited today. Report is reviewed and copy is provided.

On 3/18/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management visit. LPA met with Administrator, Ollie Vance and Resident Care Coordinator Shayla Brewster and explained the purpose of the visit. On 2/12/24 an incident report was submitted to Licensing regarding a resident choking. LPA Donato collected pertinent documents for review. No deficiencies cited today. Report is reviewed and copy is provided.

Based on record reviews, the facility has created a schedule where residents are grouped and assigned two caregivers. These caregivers that are assigned are a combination of one Spanish speaking and one English speaking or bilingual. LPA interviewed three caregivers. LPA was able to communicate with them through google translate and some hand signals. All three understand basic English. While they may not be able to speak the language easily, they can understand the basics. LPA was able to interview family members and it was mentioned that while language may be an issue, facility is addressing it by trying to hire more English-speaking caregivers. While it is a work in progress, staffing has consistently improved. Therefore, based on the interviews conducted, files reviewed, and information collected, the above allegations are found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

LPA also interviewed two residents. One mentioned that they haven't heard anything about S1 not helping or shouting at residents. Another mentioned that S1 always help with whatever they need or request. Both residents like living here and feels that they are well taken care of. Based on the above information, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis. Report was discussed with Administrator and a copy of this report is provided.

On 10/25/23 Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit. LPA Donato met with Administrator Ollie Vance and Resident Care Coordinator Shayla Brewster. LPA explained the purpose of the visit. LPA delivered an immediate exclusion letter to exclude a staff who worked in the facility before. The letter was given to and reviewed by the Administrator. This report is reviewed and discussed, and a copy is provided.

LPA checked the medication cart and saw during this time that a bottle of the medication, Lacosamide, was halfway through based on the weight. This is the fourth bottle that the facility has opened. Based on records review, a delivery from the pharmacy stated three bottles of medication, each containing 200ml. During investigation, a fourth bottle was observed as opened, and this bottle was part of the delivery from another pharmacy which also sent three, each containing 200ml. The total bottles the facility received were 6 with 200ml each. Another medication, Lorazepam was mentioned to be ordered urgently. Facility has already placed order 7 days before the medication runs out but the pharmacy hasn’t delivered right away. Kaiser pharmacy does take around 7-10 days to fulfill an order. Facilities are only able to order refills if the medication has only 7 days left for use. Based on records review, the calculations show that based on the remaining medications, the MAR, the resident was given the correct amount of dosage per the doctors order. Since the facility had enough bottles for the Lacosamide medication, they didn’t order until, they have opened the last bottle. Facility had enough bottle of Lacosamide and did not have to order until they have opened the last bottle. Therefore, based on the interviews conducted, files reviewed, and information collected, the allegations above are UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis. Report is reviewed and a copy is provided.

Based on record reviews, ADLs log indicated logs where residents had either bed baths or showers. Logs did not indicate any residents missing their bathing schedule. LPA checked the facility’s linen closet and has sufficient towels and linens for residents to use, otherwise it is provided by family members as indicated in the admission agreement packet. Regarding the allegation of facility is dirty, RP mentioned that the bathrooms & showers are filthy. Upon arriving, LPA requested a tour around the facility. LPA observed housekeeping vacuuming rooms and cleaning the bathrooms while residents are having their breakfast in the dining hall. All bathrooms, including private bathrooms, were checked and everything is in order and clean. LPA reviewed housekeeping logs for the month of August and it showed that the bathrooms were cleaned a total of 93 times. It also showed that it is cleaned three times a day. Based on an interview with administrator, facility housekeeping cleans the facility all throughout the day. Family members have no concern about the cleanliness of the facility. They feel that the facility is clean. Whenever they visit, they don’t see any issue with regards to cleanliness. Regarding the allegation that staff are not ensuring that residents are administered medication(s) according to physician's instructions, RP mentioned that whenever PRN medication is requested to be administered, staff forgets and gives excuses for not being able to give medication. Based on record reviews, all medication administration, including PRNs, has been logged. The request of RP was followed, and records show that the medication was given to the resident. Staff were interviewed about their medication procedure. Medication arrives and staff must centrally store it. There are about 7 med passes happening throughout the day. If in any case a staff forgets to give medication, then an incident report will be filed after facility contacts PCP. Therefore, based on the interviews conducted, files reviewed, and information collected, the above allegations are found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Report is reviewed and copy is provided.

LPA interviewed four family members of different residents and three of them mentioned that there were no issues with regards to feeding and hydrating the residents. However, one family member mentioned instances where resident wasn’t assisted during the time when family member visited. This instance was addressed by the family to the administrator. Four out of four residents were interviewed however not able to get some answers due to cognitive diagnosis. Regarding the allegation that Staff did not allow resident to have a visitor, according to reporting party, the director yelled at RP and "banned" RP from seeing the resident and entering the facility. Based on interviews and record reviews, the reporting party was told to leave the facility but was not banned. Since RP was violating personal rights of the resident, RP was asked to leave. RPs family member came back to the facility and was able to discharge the resident. RP did not know that he/she would be able to enter because he/she was not there the day the resident was discharged. Interviewed four residents but couldn’t get definitive answers due to cognitive diagnosis. LPA interviewed 4 family members and all of them confirmed that they can visit in the facility at any time with no issues. Regarding the allegation that due to staff negligence, resident (R1) had multiple witnessed falls causing injury, according to reporting party, R1 had multiple falls causing bruises on R1s shins, face, elbows, arms, and legs. Based on interviews and record reviews, these incidents were submitted to CCLD. R1 had only two falls that were reported. These were reported to CCLD, PCP, and responsible party. Facility reassessed R1 but couldn’t have these signed and filed due to R1 being discharged from the facility. Facility protocol for falls include calling 911 if needed, reassess residents, and work with family members for reappraisal to address resident needs. These reappraisals help with the decision if residents would need a higher level of care. Therefore, based on the interviews conducted, files reviewed, and information collected, the above allegations are found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Report is reviewed with Administrator; Ollie Vance and a copy is provided.

Regarding the allegation that staff do not inform resident's authorized representative of incidents as required, according to reporting party it’s the health care workers or other visitors who end up telling the authorized representatives about the incidents. Based on interviews and record reviews, incident reports are reported to the responsible parties. Five out of five family members interviewed mentioned that they do receive reports regarding the residents. Family members would either receive a call, a text message, voicemail or email from the facility. Six out of six staff members also mentioned the process that they follow for reporting which is to report incidents to either the Med Techs, Care Coordinator or Administrator who in turn does the incident reports and also contact the responsible parties. A record review of incident reports submitted by the facility shows that facility has contacted responsible parties. In these reports also shows the action plans that facility would do regarding the resident. Therefore, based on the interviews conducted, files reviewed, and information collected, the above allegations are found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Report is reviewed and a copy is provided.

On this day Licensing Program Analyst (LPA) Jaime Vado and John Calandra conducted an unannounced case management incident investigation visit responding to an incident that occurred on 07/25/2023. LPAs met with resident care coordinator (RCC) Shayla Brewster and explained the purpose of today's visit. The administrator Ollie Vance is not present due to conducting a resident assessment on this day. During the visit LPAs interviewed med-tech on duty and the RCC. According to the RCC the discovery of the missing medications was found on the morning of 07/25/2023 while conducting a narcotics medication count during a shift change RCC and another med-tech discovered the missing narcotics. Per RCC upon discovery of the missing narcotic she notified the administrator, Ollie Vance, who then came in to assist in locating the missing narcotic and assist in counting the narcotics to ensure an error was not made. As a result they were not able to locate the missing narcotic. Video camera footage was reviewed by RCC and the administrator and was able to identify S1 as the main suspect. The administrator then notified Menlo Park Police Department to report the incident. The police department investigated and made contact with S1 on 07/26/2023. It was confirmed that he/she had the missing narcotics per admission by S1. The missing narcotics were not returned to the facility. It was discovered that the taken narcotics were from two different residents and both residents received the narcotic as a pro re nata (PRN) while on hospice care. Neither resident missed a dose. RCC notified family members of the residents and the residents' hospice agencies. The narcotics were refilled as a result. No further missing narcotics were discovered after a subsequent audit. S1 was terminated as a result. Facility is awaiting the final police report from the police department. No citations issued. Report is reviewed with RCC Shayla Brewster.

All staff members doesn’t recall any incident where care wasn’t immediately given to residents. Even with caregivers who can’t speak English, they don’t have issues regarding communicating with the residents. As mentioned during interviews, if residents feel anything like pain, residents point on which part they feel the pain and caregivers address it right away. Caregivers are always on alert even when the residents are sitting down. They are always on the look out for cues on what that residents need or want at that time. After the investigation, this allegation is deemed to be unsubstantiated because the incident in question, based interviews, didn’t happen as everyone follows a specific protocol on how to take care of residents when incidents like falls happen. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation is UNSUBSTANTIATED. This report is reviewed and discussed with resident care director. A copy is provided.

During the visits conducted at the facility (4/17/2023 and 5/12/23) LPA observed R1 to be sitting near the Resident Care Coordinator's office or walking back and forth from his/her room to the communal living room area. Regarding the allegation that facility is short staffed, according to the reporting party, the facility is short staffed. During the investigation, LPA interviewed administrator, staff, and family members. According to the administrator, she denied this allegation and indicated she is fully staffed at the facility. In addition, 4/4 of the staff members and 4/4 family members interviewed indicated that they have not experienced any staffing concerns at the facility. Regarding the allegation that staff failed to safeguard residents' personal belongings, according to the reporting party, R1 picks up stuff from other residents' rooms. During the investigation, LPA interviewed the administrator, staff, and family members. The administrator denied this allegation and indicated that because this is a memory care facility, residents have wandering behaviors and will grab things, however if facility staff do witness a resident wandering into another resident's room and picking up their personal belongings, staff will immediately take it and return it. According to 4/4 of the staff members interviewed, they indicated that resident's personal belongings are labeled and if they find an item misplaced or something a resident has but does not belong to them, staff will take it and return it to the owner. In addition, according to 4/4 of the family members interviewed, they have observed residents wander into other resident's rooms and grab something that isn't theirs, however they understand that it is a part of the behaviors a dementia resident has. Therefore, based on the observations conducted during the visit, the above allegations are UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Report is reviewed with Administrator and a copy is provided.

Licensing Program Analyst (LPA) Grace Donato and Licensing Program Manager (LPM) Jackie Jin conducted an unannounced case management visit regarding an elopement from 04/18/2023. LPA and LPM met with Resident Care Coordinator, Shayla Brewster. Adminstrator, Ollie Vance arrived shortly. It was reported that resident (R1) eloped and was found just outside the facility after 10 minutes. A family member entered in the code to exit the facility. The door wasn't shut properly so the resident was able to go outside. After the incident the facility updated the policy, which was implemented on 4/21/23. Staff were advised that codes are only for staff members and management. The family members were also advised that the codes will be updated and would not be given to them for security and safety purposes both for the residents and the facility. A camera was also installed to monitor who punches in the codes on the exit door. In-service training was conducted on 04/17/2023 with staff regarding updated policy on giving out codes to the doors to family. No deficiency cited during today's visit. This report was reviewed with Ollie Vance and copy has been provided.

Regarding the allegation that staff are not providing activities for residents in care, according to the reporting party, staff stopped all activities for residents and the Activities Director was not allowed to come into the facility. During the investigation, LPA interviewed the administrator and the staff that provided activities for the COVID positive and negative residents. The administrator denied this allegation and indicated that the Activities Director went into each of the COVID positive residents' rooms in full PPE and provided them with activities; bingo, coloring, music, etc. for about thirty minutes to an hour everyday. In addition, the administrator stated that the Activities Director provided activities; bingo, karaoke, dancing, coloring, music, etc. for the COVID negative residents in the activities room. According to the Activities Director, she tried her best to ensure that the COVID positive residents who wandered the facility and wanted to do activities with the COVID negative residents had a face mask and stayed 6ft away from the COVID negative residents. Interviewed staff indicated when the Activities Director tested positive for COVID, the Caregivers took over and provided the activities for both the COVID positive and COVID negative residents throughout their shifts. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations above are UNSUBSTANTIATED. Report is reviewed with Administrator, Ollie Vance and a copy is provided.

On December 14, 2021, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by the Resident Care Coordinator, Adriana Garcia and the Administrator, Nancy Rubio joined shortly thereafter. LPA Charitra explained the purpose of the visit and LPA was screened at the front entrance. Administrator was able to provide LPA with screening log documentation for residents, staff, and visitors. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, and 30-day PPE supply. Bathrooms are equipped with liquid hand soap, paper towels, and hand-washing signs, however LPA recommends covering trash cans with lids in the bathrooms. COVID-19 signage was observed to be posted through-out the facility such as social distancing, COVID-19 symptoms, face coverings, cough etiquette, etc. Medications, toxins and sharps are stored appropriately and inaccessible to resident, and a comfortable temperature is maintained, lighting is sufficient for comfort. Dining area was observed to have tables maintaining social distancing. LPA requests for the following documents to be sent by 12/21/21: -LIC309 Administrative Organization -LIC308 Designation of Administrative Responsibility -LIC500 Personnel Report -Administrator Certificate -LIC610E Emergency Disaster Plan Report was reviewed with Administrator and a copy is provided.