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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200930
Report Date: 11/17/2022
Date Signed: 11/17/2022 04:54:54 PM


Document Has Been Signed on 11/17/2022 04:54 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 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: 588DATE:
11/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Valerie AlvesTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Valerie Alves, Care Center Administrator. The purpose of the visit was to inquire about an incident self-reported by the facility on 11/01/2022 that occurred on 10/29/2022. The incident involved a family member of resident R1 observing staff S1 sitting down watching television in the common area. At the same time, the family member observed R1 to be sitting in bed attempting to put on clothes and had soiled briefs in the bathroom.

The facility report states that the facility provided verbal disciplinary action for S1 and also conducted in-service training for staff to make frequent rounds to attend to residents and ensure their cleanliness.

During visit, LPA Marrufo obtained copies of S1's written disciplinary record regarding the incident as well as the training log for the in-service training that was conducted. In the written disciplinary record, staff S1 admitted to be sitting down watching television while R1 was in the bedroom alone.

During interview, Valerie Alves stated that the facility staff have been told that the television should not be put on any channel that is not meant for the residents to watch, the radio should be playing music intended for the residents if the television is not being used, and that the staff should never be on their telephones while working. The staff have also been told to ensure the cleanliness and safety of residents and to conduct frequent rounds with the residents.

LPA Marrufo reviewed R1's care plan, which states that R1 needs hands on assistance with dressing.

A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D for more information.

This report was reviewed with Jose Toribio, Director of Staff Development and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
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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Document Has Been Signed on 11/17/2022 04:54 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/24/2022
Section Cited

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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all
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of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Licensee did not ensure that resident R1 received assistance to meet R1's dressing needs, which poses a potential safety risk to residents in care.
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be submitted to CCL by POC date.

* Deficiency cleared during visit. Facility conducted staff training addressing the cleanliness, care and supervision of residents and the use of devices while on the job on 11/02/2022. *

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
LIC809 (FAS) - (06/04)
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