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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200930
Report Date: 06/16/2021
Date Signed: 06/30/2021 09:29:05 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
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: 439DATE:
06/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Mark NelsonTIME COMPLETED:
11:27 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced COVID-19 Infection Control Required - 1 Year visit and met with Mark Nelson.

LPA Marrufo toured the facility. During the tour, LPA Marrufo observed the entrance had a visitor screening station at the entrance. Hallway bathrooms had soap, paper towels, and hand washing signs. Elevators have signs posted allowing only two people per ride. The facility PPE storage room had a 30-day supply of PPEs. Staff were observed to be wearing masks. The staff break room and the resident dinning area were observed to have two chairs per table and signs to encourage social distancing. LPA Marrufo observed emergency food and hygienic supply areas.

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

This report was reviewed with Mark Nelson and a copy of the report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021
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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