435200706-12-21-2023-26-AS-KHOS-CZHPRR-20240115103312

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200706
Report Date: 12/21/2023
Date Signed: 12/21/2023 04:33:19 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/06/2020 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20201106144230

FACILITY NAME:	PALO ALTO COMMONS		FACILITY NUMBER:	435200706
ADMINISTRATOR:	LI LI		FACILITY TYPE:	740
ADDRESS:	4075 EL CAMINO WAY		TELEPHONE:	(650) 494-0760
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94306
CAPACITY:	0	CENSUS: 165	DATE:	12/21/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Li Li		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Adequate food service is not provided to residents
Staff not keeping facility free from pests
Residents room smells like urine/feces
Residents room is dirty

INVESTIGATION FINDINGS:

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On 12/21/2023, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegations. LPA met with Executive Director Li Li and explained the purpose of today's visit.

Regarding the allegation of facility not providing adequate food service to residents. Reporting party (RP) stated that the chef overcooks the food and residents are unable to eat the food. RP stated the fish was also undercooked, but no residents were ill.

Based on interviews conducted, the Executive Chef (S1) stated that they have to follow the resident’s personal diets. S1 makes sure that the residents can get what they can eat. Twelve out of twelve staff also stated that there were no issues with the food being served to the residents. The Executive Director (ED) also mentioned that there is a monthly meeting with the residents where they can address any food issues.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 26-AS-20201106144230

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: PALO ALTO COMMONS	FACILITY NUMBER: 435200706
	VISIT DATE: 12/21/2023

NARRATIVE

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Regarding the allegation of staff not keeping facility free from pests, RP stated there were cockroaches in the kitchen and the dining room.

During the interviews, one staff member (S2) observed one in the dining room along the walls. It was just one cockroach. It was reported to the head of maintenance, and they went ahead and notified pest control to come. That was the only time. Twelve out of twelve staff mentioned that they haven’t seen any pests in the facility. A resident (R1) mentioned that facility has been complimented on how it is kept clean, and they do a very good job. Seven out of seven residents mentioned that they haven’t seen cockroaches. ED also mentioned that they have a vendor for pest control that does monthly maintenance and when needed.

Regarding the allegations of resident’s room smells like urine/feces and dirty. RP stated that the residents’ rooms are “filthy”, not being cleaned and smell like feces and urine.

According to a staff member (S3), for some residents that are being changed in the room, you can smell it. It is usually during ADL care. It is when residents are being toileted or in a shower, that is when you can smell something, or when creams are applied to a resident. No smell lingers in the room. After each time the resident is cleaned, the resident’s discarded garments are put in the garbage chute. Seven out of seven residents said that their rooms are clean and have no odors or smells.

Therefore, based on the interviews conducted 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 was reviewed and a copy is provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/06/2020 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20201106144230

FACILITY NAME:	PALO ALTO COMMONS		FACILITY NUMBER:	435200706
ADMINISTRATOR:	LI LI		FACILITY TYPE:	740
ADDRESS:	4075 EL CAMINO WAY		TELEPHONE:	(650) 494-0760
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94306
CAPACITY:	0	CENSUS: 165	DATE:	12/21/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Li Li		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff not seeking medical attention for resident when choking
Facility refrigerator has mold and leaks water

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20201106144230

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: PALO ALTO COMMONS	FACILITY NUMBER: 435200706
	VISIT DATE: 12/21/2023

NARRATIVE

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Regarding the allegation that facility refrigerator has mold and leaks water, RP stated the kitchen refrigerator leaks water, “it works” but leaks puddles of water. RP reported it to a shift lead and was told not to worry about it. No maintenance worker was seen to fix it.

According to staff (S1), there were no refrigerators that have mold or leak any water. Another staff (S2) & (S3) also mentioned that after each meal, things are taken out, so we check the refrigerators every single day and checked for leftover foods. LPA also observed during the tour that there is no leak in the kitchen, the food inside the refrigerator are labeled and covered.

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 reviewed and a copy is provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4