435202819-5-21-2025-26-AS-KJAN-DGVS9T-20250521134117

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202819
Report Date: 05/21/2025
Date Signed: 05/21/2025 01:41:31 PM

Document Has Been Signed on 05/21/2025 01:41 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:	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: 179	DATE:	05/21/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Li Li		TIME VISIT/ INSPECTION COMPLETED:	01:55 PM

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On May 21, 2025, at 9:00 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. LPA met with the Executive Director (ED), Li Li, and disclosed the purpose of the inspection.

The facility consisted of two buildings with three floors each. First building was a combination of two assisted living units (elite care and assisted living), and two memory care units (meadow wing and focused care). The second building was for independent living. The ED informed the LPA that the facility had 179 residents in care at the time, including 93 in Assisted Living, 38 in memory care, and 48 in Independent Living.

At 9:45 AM, LPA initiated a walk-through of the facility, accompanied by the ED.

LPA inspected randomly selected ten (10) resident rooms in Assisted Living and Memory Care units. The rooms were found to be clean, well-lit, and equipped with the required furniture. Emergency pull cords were observed to be functioning in the resident rooms with an average response time of 5 minutes. LPA inspected the private bathrooms in these random rooms. The bathrooms contained soap, grab bars, towels, a trash can, and non-slip flooring. The hot water temperature at the sink faucets measured between 114.6°F and 116.8°F. “Oxygen in Use” signs were observed posted outside the residents’ room where oxygen was administered.

LPA inspected the main kitchen and found it clean. The refrigerator, freezer, and pantry cabinets were checked, and there was a sufficient supply of fresh perishable food for two (2) days and nonperishable staples for seven (7) days. No expired food items were found. Open food items were wrapped and dated. The dining rooms in Assisted Living and Memory Care were inspected and were found to be clean, with all furniture in good repair.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 05/21/2025

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LPA inspected activity areas, library, media room, great room, fitness center, and other commons areas and observed residents actively engaged in recreational programs and activities. Activity calendar was observed posted at various locations throughout the facility. All common areas were free from obstructions, and hallways were well-lit.

LPA inspected locked laundry stations on each floor and observed working washer and dryer units. Sharp objects, detergents, and chemicals were observed to be locked and inaccessible to persons in care.

LPA inspected the fire extinguishers mounted on the hallway walls in Assisted Living and Memory Care and found them fully charged, with the last service tag dated 12/24/2024. The smoke detectors are tested semi-annually by a third-party vendor, Performance Systems Integrated with the last inspection completed on 03/11/2025. A staff member tested the carbon monoxide detector in the basement garage in LPA’s presence, and it was found to be functional.

LPA toured the outside courtyard and patio areas and found passageways in good condition, free of obstructions, and without any blocking or tripping hazards. These areas had patio tables, chairs, and umbrellas for residents’ use. Delayed egress was observed on emergency exits and exterior exit doors were locked. No accessible bodies of water or hazards were observed.

LPA reviewed six (6) staff personnel records and five (5) resident records. The LPA observed that 5 of 5 residents had the Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. LPA observed that 6 of 6 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 6 of 6 staff members were associated with the facility.

LPA observed locked centrally stored medication carts in the Assisted Living and Memory Care units. Medications were organized separately for each resident. Narcotics were locked and the count was correct. All medication bottles and bubble packs were properly labeled. Centrally Stored Medication Records were reviewed and found to be complete.

LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster (Fire and Earthquake) Drills were conducted monthly, with the most recent drill completed on 05/15/2025.

The following updated forms are requested to be submitted to CCL by 05/28/2025:

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

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: 05/21/2025

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LIC 500: Personnel Report
LIC 308: Designation of Facility Responsibility
Certificate of Liability Insurance
Administrator Certificate(s)

No deficiencies were cited during today's visit.

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

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

LIC809 (FAS) - (06/04)

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