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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202819
Report Date: 11/14/2024
Date Signed: 11/14/2024 05:21:12 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/18/2023 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20230718091433
FACILITY NAME:PALO ALTO COMMONSFACILITY NUMBER:
435202819
ADMINISTRATOR:LI LIFACILITY TYPE:
740
ADDRESS:4075 EL CAMINO WAYTELEPHONE:
(650) 494-0760
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:250CENSUS: 187DATE:
11/14/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Li LiTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff do not provide comfortable accommodations for the residents
Resident is not afforded privacy while in care
Resident's room is in disrepair
Staff do not have planned activities for the residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Administrator (ADM) Li Li. On 07/18/2023, the Department received a complaint with the above allegations. On 07/26/2023, LPA Marrufo conducted an initial complaint investigation visit.

R1’s Admission Agreement was signed by R1’s Responsible Party (RP) on 02/20/2020. Page 23 of R1’s Admission Agreement states, “M. Substitution of Apartment We reserve the right to substitute your Apartment with another apartment in our sole discretion. We will make reasonable accommodations with respect to your preferences concerning apartment and roommate choices. We will provide you with thirty (30) days’ written notice before substituting your Apartment, unless you agree to the request for change, it is required to fill a vacant bed, or it is necessary due to an emergency. You agree to such apartment substitution and agree to pay the Monthly Fee applicable to the new apartment.”
See LIC9099-C for more information. Page 1 of 5.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
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 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/18/2023 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20230718091433

FACILITY NAME:PALO ALTO COMMONSFACILITY NUMBER:
435202819
ADMINISTRATOR:LI LIFACILITY TYPE:
740
ADDRESS:4075 EL CAMINO WAYTELEPHONE:
(650) 494-0760
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:250CENSUS: DATE:
11/14/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Li LiTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Insufficient staffing for the residents while in care
INVESTIGATION FINDINGS:
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R1’s Physician’s Report states that R1 has motor impairment/paralysis, is not able to transfer independently to and from bed, and is bedridden.

During interview on 07/26/2023, R1 stated that there have been times when staff have been late to get R1 out of bed. R1 stated staff are overscheduled and there are only 4-5 staff per day. R1 stated there have been several times when R1’s physical therapist had to give R1's exercises in bed instead of in R1’s wheelchair. R1 stated R1’s physical therapist should be giving R1 exercises in R1’s wheelchair. R1 stated these incidents occurred between 1 PM and 2 PM.

On 08/03/2023, LPA Marrufo conducted a telephone interview with Occupational Therapist OT1. OT1 stated to work with R1 and has met with R1 2-3 times per week to conduct weight training exercises.

See LIC9099-C for more information. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 26-AS-20230718091433
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/14/2024
NARRATIVE
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OT1 stated to be privately paid for by R1’s family and is not a facility staff. OT1 stated that facility staff have left R1 in bed as late as 2 PM. OT1 stated R1 likes to get out of bed by 11 AM or by lunchtime. OT1 stated to not know how many times staff left R1 in bed, but stated it was an ongoing issue for about a month. OT1 stated staff would tell OT1 that they left R1 in bed because R1 had not had a bowel movement yet and it would be easier for R1 if R1 was left in bed. However, OT1 stated R1 would tell OT1 that the staff would just leave R1 in bed.

Based on interviews, there is preponderance of evidence to prove the alleged violations did occur. Therefore, the allegation is substantiated.

See 9099-D for deficiencies cited per the California Code of Regulations, Title 22.

This report was reviewed with Administrator Li Li and a copy of this report and appeal rights were provided.


Page 2 of 2.



END REPORT
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 26-AS-20230718091433
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/15/2024
Section Cited
CCR
87411(a)
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87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more,
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Licensee agrees to submit a plan of correction to ensure that staff are sufficient in numbers and competent to provide the services necessary to meet resident needs, including assisting residents in transferring out of bed.
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sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by: resident R1 was left in bed multiple times past 1 PM, which poses an immediate health risk to residents in care.
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Licensee agrees to conduct in-service training with staff and submit staff training records to CCL once training is completed, including training topics, names of staff trained, training dates, and names and qualifications of trainer(s).
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 26-AS-20230718091433
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/14/2024
NARRATIVE
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LPA obtained copies of letters addressed to facility residents and family members on 12/15/2022 and 05/09/2023, as well as an Outlook calendar appointment with a link to a Zoom meeting that occurred on 06/02/2023. The letter dated 12/15/2022 states that there will be a renovation project that will include the facility entryway, courtyard, reception area, administrative area, and aspects of the dinning room. The letter states WellQuest leadership would be on campus on 12/20 at 2:30 PM to meet with residents. The letter from 05/09/2023 states that renovations at the community would begin on 06/05/2023 and there would be a community meeting to ask questions about the renovation project on 05/24/2023. The letter requested an RSVP by 05/20/2023. The Outlook calendar appointment is for a Zoom meeting that occurred on 06/02/2023 and had the subject “Palo Alto Commons Renovation: Community Meeting.”

During interview on 07/26/2023, ADM stated that ADM gave RP a tour of the proposed new apartment for R1 since RP was complaining that there was too much construction noise around R1’s current apartment. ADM stated to have told RP that the new apartment does not have a rolling shower like R1’s current apartment. ADM stated to have told RP that R1 would be more comfortable in R1’s current apartment. ADM stated to have told RP that there is a shower room on the second floor for residents whose apartments do not have wheelchair accessible showers.

LPA Marrufo obtained copies of emails between Administrator (ADM) Li Li and RP that are dated from 06/12/2023 to 07/17/2023. On 06/12/2023, ADM sent an email to RP confirming a meeting and the subject of the email is “Re: Moving [R1] to new room.” In an email on 06/14/2023, ADM told RP that another apartment will be on hold for R1 to move into should RP approve the move. On 06/19/2023, RP responded to ADM’s email and stated that RP wants to move R1 to the new apartment.

On 07/10/2023, RP emailed ADM stating that R1’s new apartment has no privacy, has a bathroom and kitchen that is not accessible by wheelchair, has a bedroom with a broken door, and has no privacy as it faces a walkway used frequently used by employees. RP requested a reduction of $2,500 to R1’s monthly bill to compensate for RP’s complaints about R1’s new apartment.

Page 2 of 5.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 26-AS-20230718091433
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/14/2024
NARRATIVE
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On 07/14/2023, ADM responded to RP’s previous email and apologized for the broken bedroom door. ADM stated the maintenance team would repair the door. ADM stated to have discussed the inconvenience of the shower room in the new apartment during the tour, but RP had wanted to move R1 away from the ongoing construction. ADM offered R1 a monthly rental credit of $1,000 until the renovation project was completed and R1 could return to R1’s original apartment. ADM stated staff members are requested not to access the side door to ensure R1’s privacy unless there is an emergency.

On 07/17/2023 at 11:35 AM, RP responded to ADM’s previous email and did not agree to accept the $1,000 monthly credit. RP stated, “Please grant the reduction of $2,500 and we will consider the matter closed.”

On 07/17/2023 at 4:18 PM, ADM responded to RP’s previous email respectfully disagreeing with RP’s proposal of a $2,500 monthly credit and again proposed a $1,000 monthly credit.

On 07/17/2023 at 5:12 PM, RP stated to have been disappointed in ADM’s response.

On 07/17/2023 at 5:18 PM, ADM stated that ADM’s supervisor has approved of RP’s request and R1 will receive monthly credits of $2,500 from 07/01/2023.

On 07/17/2023 at 5:32 PM, RP accepted the $2,500 monthly credit.

On 07/14/2023, ADM sent an email to RP and stated staff members are requested not to access the side door to ensure R1’s privacy unless there is an emergency.

During interview on 07/26/2023, R1 stated to have privacy in the new apartment. R1 stated there is an exit door in the bedroom and R1 has been cautioned not to open it. R1 stated a staff comes each night to ensure the door is closed. R1 stated R1 is able to close the blinds if R1 wants privacy.

Page 3 of 5.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 26-AS-20230718091433
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/14/2024
NARRATIVE
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During visit on 07/14/2023, LPA Marrufo observed R1’s new apartment. LPA observed a sliding glass door in R1’s bedroom that faced an exterior walkway. The door had a metal pole attached to it that prevented the door from sliding open. LPA observed two sets of window curtains installed over the sliding glass door.

On 06/14/2023, ADM sent RP an email and proposed a move-in date of 06/22/2023 for R1 to move into the new apartment.

On 07/10/2023, RP sent ADM an email stating that the door facing the exterior of the building in R1’s bedroom was broken.

On 07/14/2023, ADM sent an email to RP apologizing for the inconveniences caused by the broken door in the bedroom. ADM stated a work order has been sent to the maintenance team to repair the bedroom door.

During visit on 11/14/2024, LPA Marrufo interviewed staff S1, Director of Environmental Services. S1 stated that RP stated that R1’s sliding glass door was not locking. S1 stated to have observed the sliding glass door and the door had a pole installed that latched in order to lock the door. S1 stated that the pole had to be flipped upwards to be latched and locked and most people thought that the pole would need to be latched downwards to lock. S1 stated there was a “flipper” at the bottom of the door that allowed the door to be open about 3-4 inches for ventilation purposes. S1 stated the “flipper” was installed on the sliding glass door because it is an exterior door and due to safety concerns, the door was not meant to be opened all the way. S1 stated to have not observed any damage to the door. S1 stated there is no record of a work order put in for the door on either June or July of 2023. S1 stated to have taken a video of the door and showed in the video how the door was locked with the latch. S1 stated to have shown the video to ADM on S1’s mobile phone. S1 stated to have not discussed the door or shown the video to RP or R1. S1 stated that usually if there are any problems with exterior doors, the exterior doors are either repaired or replaced right away, since the exterior of the facility is a safety concern. S1 found the video on S1’s mobile phone and showed the video to LPA Marrufo. S1 showed LPA the video of S1 flipping up the latch, sliding open the door, sliding the door closed again, locking the door, and lowering the pole. S1 also showed the flipper at the bottom railing that prevents the sliding glass door from fully opening. S1 stated the video is dated 07/17/2023.

Page 4 of 5.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 26-AS-20230718091433
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/14/2024
NARRATIVE
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During visit on 11/14/2024, LPA Marrufo toured the apartment into which R1 had been transferred. LPA observed that the bedroom now had a wall with a window instead of a sliding glass door. S1 stated the sliding glass door had been changed to a window and wall as part of the facility renovation process.

During visit on 11/14/2024, ADM stated during interview to have discussed the proper way to lock the sliding glass door with RP.

During interview on 07/26/2023, R1 stated that staff provide activities such as bingo, book group, and rest and relaxation. R1 stated many residents attend the activities.

LPA Marrufo obtained the activity calendars for the months of June and July 2023. The calendars indicated that there were 5-6 activities scheduled each day.

LPA Marrufo obtained copies of the Book Club Sign-Up forms for the months of June and July 2023. R1’s name is listed on both sign-up forms.

During visit on 07/26/2023, LPA Marrufo toured the facility. During the visit, the facility was still undergoing renovation. LPA observed 8 residents in a facility meeting office room that had been repurposed as an activity room. The residents were watching a video on a television that had been installed in the office room. LPA photographed an activity schedule posting for 07/27/2023 that posted 6 different activities scheduled. The activities were being held in the Hobby Room, Dinning Room, and Lobby.

Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22.

This report was reviewed with Administrator Li Li and a copy of this report was provided.

Page 5 of 5. END REPORT.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8