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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200706
Report Date: 05/27/2021
Date Signed: 05/28/2021 12:01:18 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: 148DATE:
05/27/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:04 PM
MET WITH:Li LiTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA), Steve Nguyen conducted an unannounced tele-visit Case Management with Administrator(AD) Li Li . The incident that initiated the visit was self reported by the facility in an LIC624 Unusual Incident Report on 05/27/2021. The incident occurred on 05/21/2021 and involved a staff reported witnessing staff hitting a resident. The reporting staff reported the incident to the facility on 5/24/2021. Per AD:

On 5/24/2021, Charge Nurse gave a physical examination to R1 and there was
no apparent injury, bruise, laceration, redness, or cuts found.

On 5/24/2021, facility contacted R1's daughter and updated her on R1's status.

Suspected Abuser was immediately suspended pending facility's internal investigation.

An in-service was given to staff members in the Memory Care Unit for Elder Abuse and Proper Reporting Time, and How to Give Care to Residents with Dementia.

At approximately 4:18 PM, LPA conducted an interview with R1; however, R1 was limited to yes or no response. R1 does not remember incident. LPA asked and received R1's permission to inspect head. Inspection revealed no apparent injury.

LPA requested the following documents to be sent to Department by 5/28/2021: Physician's Orders, Needs and Services Plan, and Plan of Correction.

No deficiencies were cited at this time. This report was reviewed with Li Li. A copy of this report will be sent to her for her to sign and return to Department
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Steve NguyenTELEPHONE: (650) 676-0051
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE:
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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