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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200930
Report Date: 04/06/2023
Date Signed: 04/06/2023 03:00:36 PM


Document Has Been Signed on 04/06/2023 03:00 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: 538DATE:
04/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Valerie AlvesTIME COMPLETED:
03:15 PM
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Licensing Program Analysts (LPAs) David Marrufo and Ravi Patel conducted an unannounced Case Management visit and met with Valerie Alves, Care Center Administrator. The purpose of the visit was to respond to a Death Report and Incident Report regarding resident R1 falling on a treadmill in the facility on 03/25/2023 and passing away on 03/29/2023.

During visit, LPAs obtained copies of R1's Admission Agreement and Emergency Contact Face Sheet. LPA's reviewed R1's resident records and did not observe any documents indicating assisted living services were provided to R1 or that R1 needed supervision.

LPA's obtained a copy of R1's Fitness Center Release and Waiver form which R1 signed on 08/25/2015.

LPAs discussed with Mark Nelson, Associate Executive Director of Independent Living, about the facility's plan to remind resident about proper use of exercise equipment.

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

This report was reviewed with Valerie Alves, Care Center Administrator, and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
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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