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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200706
Report Date: 12/03/2020
Date Signed: 12/03/2020 02:20:20 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:
12/03/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Li LiTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) David Marrufo and California Department of Public Health HFEN Nurses Janet Hayes and Helen Widegren conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility. LPA met with Administrator Li Li and Assistant Administrator Charito Amoranto.

During today's tele-visit, the following recommendations were made to the facility:

1. Staff in contact with other staff and residents should use N95 masks. Facility may implement extended use policies on masks so that staff can use them for 3-5 days to extend supply.
2. Staff should use disposable gowns when entering isolation rooms and in resident rooms in the memory care unit
3. PPE trash is considered regular trash, not red bag trash
4. Facility to obtain wipes for elevator buttons
5. Disposable masks should be made available closer to entrance for visitors
6. Facility staff should review PPE donning, doffing and use videos and resources to be sent by HFEN Janet Hayes
7. Paper bags should be provided in staff break rooms to store N95 masks so masks are not contaminated by table tops
8. Resident activities should be done in "social bubble" groups to mitigate spread

This report was reviewed with Li Li. A copy of the report will be sent to her for it to be signed and returned to CCL.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2020
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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