435202819-3-4-2025-26-AS-KJAN-DEFR4X-20250304114216

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202819
Report Date: 03/04/2025
Date Signed: 03/04/2025 11:42:30 AM

Document Has Been Signed on 03/04/2025 11:42 AM - 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:	PALO ALTO COMMONS		FACILITY NUMBER:	435202819
ADMINISTRATOR/ DIRECTOR:	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: 186	DATE:	03/04/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Li Li		TIME VISIT/ INSPECTION COMPLETED:	11:55 AM

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On March 04, 2025, at 9:00 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident inspection visit regarding a reported Theft and Loss incident that occurred on 02/24/2025. The facility also reported a SOC 341 for the same Theft and Loss incident. Upon arrival, the LPA was greeted by the Executive Director (ED), Li Li. The LPA disclosed the purpose of the visit. The ED informed the LPA that the total facility census was 186.

According to the ED, on 02/15/25, a hospice resident (R1) passed away at the facility in the presence of hospice nurse and facility staff member. No R1's family members were present. On 02/23/2025, R1’s family member (FM1), arrived at the facility to pack R1’s belongings. FM1 came to the front desk and requested to unlock R1’s room. Floor shift leader unlocked the room. ED stated that about 30 minutes later, FM1 raised concerns to ED that some of the items were missing from R1's room - watch, wallet and Apple iPad. ED suggested FM1 to thoroughly check R1’s personal items and meet with ED the next day, when FM1 had a check list of missing items. FM1 agreed to meet ED the next day.

On 02/24/2025, FM1 met with ED and reported following missing items, listed with their Dollar ($) value: 1) wallet worth $25.00, 2) new watch worth $500.00, 3) Apple iPad tablet worth $1,00.00, 4) Camera equipment worth $10,000.00, 5) music box worth $750.00, and 6) Faberge Pinecone Egg worth 2,000.00. The total value of missing items was $14,275.00. ED stated that R1 moved into the facility on 11/27/2024, initially to room #108 and then to room #113. Family hired movers during both the moves. The facility checked the room #108 to make sure nothing was left behind in the room, after R1 moved to room #113.

On 2/24/2025, ED and FM1 thoroughly checked R1’s apartment for missing items. ED called Palo Alto Police Department (PD). PD’s officer arrived and searched R1’s apartment for the missing items and obtained the details of the missing items. A PD case was opened.

Continued on LIC809-C

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

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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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: PALO ALTO COMMONS	FACILITY NUMBER: 435202819
	VISIT DATE: 03/04/2025

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ED stated that during the last few days of the resident's passing there were quite a few visitors. Three (3) hospice staff visited R1 during the day of their passing. On 02/17/2025, a medical equipment company hired by the Hospice came to the facility to dissemble the hospital bed and pick up the bed and other equipment like portable oxygen tank.

ED stated, at this moment, none of the visitors can recollect seeing these missing items. Facility was currently waiting to hear back from the police department.

LPA reviewed R1’s admissions agreement. FM1 was designated to remove R1’s personal property upon death. FM2 was R1’s POA, whose signed the admission agreement. On, 11/25/2024, FM2 signed and dated resident’s personal property and valuables form, but never declared the items on the form. LPA reviewed facility’s loss and theft policy, and in service training record for theft and loss policy. LPA reviewed the visitor’s sign in sheet record for R1. LPA reviewed LIC 9060 Resident Theft and Loss Record listing the items that were reported missing by FM1.

No deficiencies were cited during today's visit.

An exit interview was conducted with the Executive Director. A copy of this report was left with the Executive Director, Li Li, whose signature on this form confirms receipt of the report.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025

LIC809 (FAS) - (06/04)

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