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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202819
Report Date: 06/29/2021
Date Signed: 06/29/2021 02:49:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:PALO ALTO COMMONSFACILITY NUMBER:
435202819
ADMINISTRATOR:LI LIFACILITY TYPE:
740
ADDRESS:4075 EL CAMINO WAYTELEPHONE:
(650) 494-0760
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:250CENSUS: 138DATE:
06/29/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Li LiTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Prelicensing visit and met with Administrator Li Li.

During visit, LPA Marrufo toured the facility. LPA observed 12 resident living units. Each living unit had water temperatures from 105 F to 114 F. Each bathroom had showers with grab bars. Each bedroom had beds with bedding, dresser drawers, and functioning lighting. LPA Marrufo tested the emergency pull cords and found staff responses ranged from 52 seconds to 10 minutes.

LPA Marrufo toured the resident dinning area and kitchen. The kitchen area had a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days. 8 fire extinguishers were found to have service tags updated on 12/17/2020. LPA Marrufo observed 2 activity rooms and observed the activities calendar.

LPA Marrufo reviewed resident centrally stored medication logs and resident records for residents R1-R8 and found them to be complete. The personnel records for staff S1-S8 were reviewed and found to be complete. The facility emergency disaster drill logs indicate that drills were conducted on 05/27/2021 and 04/28/2021. The fire alarm system was last tested on 10/27/2020.

LPA Marrufo reviewed the Component III presentation with Administrator Li Li during visit.

Prelicensing is complete and the facility has no deficiencies. This report was reviewed with Administrator Li Li 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: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
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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