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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200930
Report Date: 11/24/2020
Date Signed: 11/24/2020 02:51:40 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:VI AT PALO ALTOFACILITY NUMBER:
435200930
ADMINISTRATOR:STEVE A. BRUDNICKFACILITY TYPE:
741
ADDRESS:620 SAND HILL ROADTELEPHONE:
(650) 853-5000
CITY:PALO ALTOSTATE: CAZIP CODE:
94304
CAPACITY:876CENSUS: 548DATE:
11/24/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mark NelsonTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) David Marrufo and California Department of Public Health HFEN Nurse Angela Brand 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 facility staff Associate Executive Director Yannick Gilbert and Care Center Administrator Mark Nelson. CCLD Regional Manager Vivien Helbling, Santa Clara County Department of Public Health (SCCDPH) representative Sally Thach, and CCLD Continuing Contracts Bureau Manager Allison Nakatomi also attended the Zoom meeting.

During the meeting, CCLD and SCCDPH representatives discussed with Mr. Gilbert and Mr. Nelson the importance of the facility to be responsive to communications with CCLD and SCCDPH as well as providing line lists when requested. In addition, CCLD and SCCDPH discussed a COVID-19 positive resident who was hospitalized and Mr. Nelson and Mr. Gibson stated that the resident was hospitalized per doctor's orders.

During today's tele-visit, HFEN Angela Brand did not have any recommendations after being given a virtual tour of the facility's entrance, signs, PPE supplies, and isolation room entrance.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Mark Nelson. A copy of the report will be sent to him 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: 11/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2020
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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