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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200930
Report Date: 12/23/2021
Date Signed: 12/23/2021 03:25:39 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: 532DATE:
12/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Yannick GilbertTIME COMPLETED:
03:38 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Yannick Gilbert. The purpose of the visit was to obtain documents for resident R1, whom the facility reported to have been found deceased by staff at the facility on 12/20/2021, and to conduct a health and wellness check with residents.

During visit, LPA Marrufo requested copies of R1's resident file and requested a copy of the facility staffing schedule for December 2021. Mr. Gilbert stated that he could provide copies of the staff schedule by Wednesday, 12/29/2021.

LPA Marrufo conducted health and wellness checks for residents R2-R6, who stated to have been feeling well, reported to be provided with meals by the facility and with assistance with medications by staff if needed.

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

This report was reviewed with Yannick Gilbert 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: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
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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