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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200930
Report Date: 01/24/2022
Date Signed: 01/24/2022 04:15:54 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: 640DATE:
01/24/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Mark NelsonTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) David Marrufo, Licensing Program Manager Jackie Jin, and Nurse Cristina Wong conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility and met with Mark Nelson.

The Mark Nelson reports that there are currently 0 COVID-19 positive residents and 9 COVID-19 positive staff.

During today's tele-visit, the following recommendations were made to the facility by Nurse Cristina Wong:

1. Place social distancing signs in activity rooms.
2. Place hand washing sign near the kitchen hand washing station.

No deficiencies were cited as per California Code of Regulations, Title 22.

This report was reviewed with 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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022
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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