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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202819
Report Date: 05/28/2025
Date Signed: 05/28/2025 10:07:41 AM

Document Has Been Signed on 05/28/2025 10:07 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: 182DATE:
05/28/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Li LiTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
NARRATIVE
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On May 28, 2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident inspection visit regarding a reported staff-to-resident physical abuse incident that occurred on 05/17/2025. The facility also reported SOC 341 for the same physical abuse incident. Upon arrival, the LPA was greeted by the Executive Director (ED), Li Li. The LPA disclosed the purpose of the visit.

LPA interviewed ED and Resident R1.

ED stated that on 05/17/2025, at 8:00 AM, Caregivers S1 and S2 were assisting a R1 in R1’s room during the AM shift. R1 was combative and agitated. R1 was hitting caregiver S1 on the arms, spitting on S1's face, and kicking S1 with their legs. S1 inappropriately slapped R1’s arm and tapped R1’s mouth using threatening language. S2 reported the incident to S4. Charge Nurse S3 assessed R1 and conducted a full body exam, finding no areas of redness, or discoloration, and no painful or tender areas. No injuries were noted. S1 was suspended and removed from the community. The incident was reported to S4, who was the manager on duty. Upon reviewing the situation, S4 immediately suspended S1 and escorted S1 off the community. S4 contacted the R1’s responsible party (RP) to inform them of the incident. R1’s Primary Care Physician (PCP) was notified of the incident on 05/20/2025.

ED stated S1 was officially terminated yesterday, 05/27/2025. R1 have been on alert charting. R1 is fine, calm at baseline and was on frequently safety checks. ED further stated that Palo Alto PD was called on 05/22/2025, but no police has showed up, but there was a phone interview and R1’s and S1’s personal information was taken.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2025
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: 05/28/2025
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RP was called on 05/17/2025 and RP had no concerns. ED followed up with RP over the phone again on 05/27/2025 to give update on R1. ED stated they will continue with elder abuse, resident’s rights, and policies of workplace violence prevention for California training for facility staff members.

LPA conducted a wellness check on R1 by visiting their room. R1 was observed to be watching TV, closing his eyes often, and answered LPA questions by verbally responding and nodding. R1 stated he had no pain and doesn’t remember anyone tapping his mouth or slapping his arms or spitting on their face. R1 further stated no one used foul or threatening language with them.

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.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC809 (FAS) - (06/04)
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