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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200706
Report Date: 10/01/2020
Date Signed: 10/01/2020 01:37:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PALO ALTO COMMONSFACILITY NUMBER:
435200706
ADMINISTRATOR:LI LIFACILITY TYPE:
740
ADDRESS:4075 EL CAMINO WAYTELEPHONE:
(650) 494-0760
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:250CENSUS: 165DATE:
10/01/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Charito AmorantoTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Incident visit over telephone and spoke with Assistant Executive Director Charito Amoranto. The visit was conducted over telephone due to the ongoing COVID-19 Shelter-in-Place order throughout the county and state. The incident that initiated the visit was self-reported by the facility in an LIC624 Unusual Incident Report on 09/24/2020. The incident occurred on 09/22/2020 and involved a facility nurse who forgot to provide 9:00 PM medications to fourteen residents.

LPA Marrufo spoke with Ms. Amoranto, who stated that the nurse had received disciplinary actions and that staff had received training on medication following the incident. Ms. Amoranto stated that when interviewed the nurse stated to have forgotten to administer the 9:00 PM medications and had forgotten to schedule the medications on the staff's own job list.

Ms. Amoranto stated that resident primary care physician's were notified and staff monitored residents for twenty-four hours after the incident and did not observe any adverse reactions amongst the fourteen residents.

No deficiencies were cited at this time. This report was reviewed with Charito Amoranto. A copy of this report will be sent to her for her to sign and return to CCL.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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