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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202819
Report Date: 03/11/2025
Date Signed: 03/11/2025 10:20:57 AM

Document Has Been Signed on 03/11/2025 10:20 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 COMMONSFACILITY NUMBER:
435202819
ADMINISTRATOR/
DIRECTOR:		LI LIFACILITY TYPE:
740
ADDRESS:4075 EL CAMINO WAYTELEPHONE:
(650) 494-0760
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY: 250CENSUS: 183DATE:
03/11/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Li LiTIME VISIT/
INSPECTION COMPLETED:
10:35 AM
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On March 11, 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 an incident when the resident (R1) presented with a sudden change of condition and the nurse assessed and observed that the resident had removed his supra pubic catheter. 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 183.

Based on the review of the facility file records, the facility did not have an exception granted in place for R1’s suprapubic catheter, a restricted health condition.

LPA and ED had a phone conversation with Mariam Perez, Vice President of Clinical Services at Wellquest Living (VP). VP stated they had a phone call with CDSS on March 7, 2025 and were told there was no need to file an exception request for catheter.

ED stated they had the requested documents ready to submit for an catheter exception request, if there was a need to be.

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: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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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