435202819-4-7-2022-26-AS-KHOS-CDWPQ7-20220428113041

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202819
Report Date: 04/07/2022
Date Signed: 04/07/2022 03:51:54 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/30/2022 and conducted by Evaluator Marybeth Donovan

COMPLAINT CONTROL NUMBER: 26-AS-20220330151136

FACILITY NAME:	PALO ALTO COMMONS		FACILITY NUMBER:	435202819
ADMINISTRATOR:	LI LI		FACILITY TYPE:	740
ADDRESS:	4075 EL CAMINO WAY		TELEPHONE:	(650) 494-0760
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94306
CAPACITY:	250	CENSUS: 152	DATE:	04/07/2022
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Li Li		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility does not have hot water for residents in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to open a 10 Day Complaint investigation. LPA met with Li Li Executive Director (ED) and Charito Amoranto Assistant Executive Director and explained the purpose of the visit. LPA toured the facility inside and out.

LPA interviewed ED, 2 staff, and 6 residents. LPA obtained resident roster, incident report dated 4/1/2022, water temperature logs and resident communication dated 3/8/2022.

ED stated on March 8, 2022 that they identified plumbing issues with water temperature and immediately contacted a plumbing contractor to resolve. The system was stabilize the same day. The facility has a tankless water heater system and now has installed a 120 gallon storage and mixing tank to provide a ready supply of hot water to the system.

Page 1 of 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

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-20220330151136

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: PALO ALTO COMMONS	FACILITY NUMBER: 435202819
	VISIT DATE: 04/07/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA observed 6 tankless water heaters to include storage and mixing tank in operation. LPA observed the water temperatures in 3 resident bathrooms to range from 105 to 115. S3 stated they randomly checking room temperatures daily on each floor and record the readings to monitor the hot water temperature provided to residents.

3 of 6 residents did not have any hot water temperature concerns. 2 of 6 residents interviewed stated that they were having problems with the hot water temperature not being hot enough and or hot water taking too long to get. 1 of 6 stated the water temperature was inconsistent. 2 of 6 stated the issue has been resolved.

The Department has investigated the above allegation. Based on information from interviews, records reviewed, and observations although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No Deficiencies cited under California Code of Regulations Title 22

Exit interview conducted with Li Li Executive Director and Charito Amoranto Assistant Executive Director a copy of this report provided.

Page 2 of 2

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2