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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200706
Report Date: 05/19/2021
Date Signed: 05/19/2021 02:44:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
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: 148DATE:
05/19/2021
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 Nurse Cristina Wong conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility. LPA Marrufo, and Nurse Cristina Wong met with Administrator Li Li.


The Administrator reports that there are currently 0 COVID-19 positive residents and 0 COVID-19 positive staff. During today's tele-visit, the following recommendations were made to the facility by Nurse Cristina Wong:

1. Continue to follow facility Mitigation Plan
2. Continue training and education of staff in COVID-19 mitigation measures.

No deficiencies were cited as per California Code of Regulations, Title 22. This report was reviewed with with Administrator Li Li. A copy of the report will be sent to him for it to be signed and returned to CCL.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
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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