435200930-4-6-2023-26-AS-DMAO-CQMTRY-20230406145819

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200930
Report Date: 04/06/2023
Date Signed: 04/06/2023 02:58:30 PM

Document Has Been Signed on 04/06/2023 02:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	VI AT PALO ALTO		FACILITY NUMBER:	435200930
ADMINISTRATOR:	STEVE A. BRUDNICK		FACILITY TYPE:	741
ADDRESS:	620 SAND HILL ROAD		TELEPHONE:	(650) 853-5000
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94304
CAPACITY:	876	CENSUS: 538	DATE:	04/06/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Valerie Alves		TIME COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) David Marrufo and Ravi Patel conducted an unannounced Case Management Visit and met with Valerie Alves, Care Center Administrator. The visit was conducted in response to an Unusual Incident Report that was self-reported by the facility on 03/28/2023 regarding resident R1 alleging that staff S1 physically abused R1 on 03/26/2023. During visit, LPAs obtained copies of the Internal Investigation Report that the facility made in response to the incident. The Internal Investigation Report stated that staff S1 was assisting R1 on the toilet on 03/26/2023 at around 3:30 AM. The report states S1 was assisting R1 and then S1 stood in front R1's doorway and redirected R1 back to R1's bed. The report states R1 was agitated, so S1 called staff S2 for assistance, and R1 reported to S2 that S1 hit R1. The report states a wellness check was conducted on R1 and no injuries or signs of abuse were observed. The report states the next day, R1's family member (FM1) arrived at the facility and gave R1 a walk after lunch. The report states FM1 stated R1 seemed fine. During visit, LPAs conducted a telephone interview with FM1, who stated that R1 seemed fine and FM1 did not observe any signs of abuse on R1. LPAs attempted to conduct a telephone interview with S1, but were only able to leave voice mail on S1's telephone. LPAs conducted a telephone interview with S2, who stated that S2 came into R1's room to assist R1 in getting back into bed and S2 told S1 to leave the room. S2 stated to have told S1 to return to the dinning area where S2 had been observing in order to have a staff at that area. S2 stated to have not observed any signs of abuse on R1 and did not recall R1 stating to have been physically abused. LPAs interviewed Valerie Alves and staff S3 during visit. LPA Marrufo interviewed resident R1 during visit and R1 stated to have not experienced any incidents of physical abuse with staff. See LIC809-C for more information. Page 1 of 2.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

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

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: VI AT PALO ALTO	FACILITY NUMBER: 435200930
	VISIT DATE: 04/06/2023

NARRATIVE

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LPAs discussed with Valerie Alves the facility's plan to prevent abuse, which includes regular training of staff in regards to explaining kinds of abuse, preventing abuse, reporting abuse, and ensuring the safety of residents.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Valerie Alves, Care Center Administrator, and a copy of the report was provided.

Page 2 of 2. END REPORT.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2