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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200930
Report Date: 01/27/2022
Date Signed: 01/27/2022 01:59:13 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/21/2022 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20220121173610
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:
01/27/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mark NelsonTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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9
Facility not following physician's orders.
Facility withheld resident's medical records.
Facility not meeting resident's needs.
INVESTIGATION FINDINGS:
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LPA Marrufo conducted an unannounced complaint investigation initial visit and met with Mark Nelson.

During the visit, LPA Marrufo obtained copies of the resident roster for Assisted Living and Independent Living. LPA Marrufo reviewed the rosters and observed that resident R1 is a resident in the Independent Living unit of the facility. LPA Marrufo observed that the Independent Living unit has its own entrance and is a separate building. During interview with the reporting party, the reporting party stated that R1 does not receive any assisted living care services.

See LIC9099-C for more information. Page 1 of 2.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 26-AS-20220121173610
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 ALTO
FACILITY NUMBER: 435200930
VISIT DATE: 01/27/2022
NARRATIVE
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This agency has investigated the complaint allegations listed. Based on interviews and review of records, the CCLD has found that the complaint allegations are UNFOUNDED, meaning that the allegation were false, could not have happened and/or is without a reasonable basis.

Resident R1 is not an Assisted Living resident and does not receive any assisted living services.

No deficiencies were cited 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: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2