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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200930
Report Date: 01/09/2025
Date Signed: 01/09/2025 11:06:09 AM

Document Has Been Signed on 01/09/2025 11:06 AM - 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 ALTOFACILITY NUMBER:
435200930
ADMINISTRATOR/
DIRECTOR:		JOHN KOSELAKFACILITY TYPE:
741
ADDRESS:620 SAND HILL ROADTELEPHONE:
(650) 853-5000
CITY:PALO ALTOSTATE: CAZIP CODE:
94304
CAPACITY: 876CENSUS: 570DATE:
01/09/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Neda Armanfar and Andrea FademTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On January 09, 2025, at 9:00 AM, Licensing Program Analyst (LPA) Kiran Jain arrived at the facility to conduct a Case Management – Other Inspection. Upon arrival, the LPA was greeted by the Director of Assisted Living (DAL), Neda Armanfar and Director of Nursing (DN), Andrea Fadem. The LPA disclosed the purpose of the visit.

The purpose of this inspection visit was to deliver a "Decision and Order" for the exclusion of staff S1. The Department of Social Services Community Care Licensing Division has issued a Decision and order for the exclusion of S1, effective 12/30/2024. S1's Home Care Aide registration has been revoked or deemed forfeited. A copy of the Decision and Order was provided and discussed with DAL and DN.

DN stated that S1 was never an employee at the facility and is not on the payroll. DN stated that they received a copy of revocation and exclusion notice for S1 but didn’t know what to do with it since S1 was not an employee or Private Duty Assistant (PDA) at the facility. DN stated that S1 will be put on their “Do Not Return” list.

A copy of facility’s Visitor’s Log for past (1) year was provided to the LPA and no records were found for S1. DN stated they will reach out to all the private care giving agencies that the residents use. A copy of payroll screenshot was provided to the LPA, showing no records for S1 on the payroll system. A copy of S1’s disassociation/separation in the Guardian system was provided to the LPA.

LPA advised the facility that S1 is not allowed to work and volunteer in any licensed facilities.

DN stated they will email a copy of LIC500 Personnel Report to the LPA by 01/15/2025.

No deficiencies were cited during today's visit.

An exit interview was conducted. A copy of this report was discussed and left with the Director of Assisted Living, Neda Armanfa, whose signature on this form confirms receipt of this report.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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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