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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202819
Report Date: 07/31/2025
Date Signed: 07/31/2025 10:19:49 AM

Document Has Been Signed on 07/31/2025 10:19 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: 184DATE:
07/31/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Li LiTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
NARRATIVE
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On July 31, 2025, 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 07/17/2025. The facility also reported SOC 341 for the same Theft and Loss incident. Upon arrival, the LPA met with the Executive Director (ED), Li Li and disclosed the purpose of the visit. The ED informed the LPA that the total facility census was 184.

ED stated that during a care conference, R1 reported that four art pieces were missing. These pieces were originally stored in R1’s closet, wrapped in a blanket. They were only paper art pieces and had not yet been placed in frames. The DPOA, who attended the meeting, brought copies of similar art pieces to show, but they were not the original items. The DPOA stated that R1 purchased the art pieces at a street fair for $40 each, totaling $160 for all four pieces.

The ED asked the DPOA if they had thoroughly searched R1’s room, and the DPOA confirmed that they had. ED also asked if the large off-site storage unit rented by R1 had been checked, as the DPOA frequently moved R1’s belongings between the room and the storage space. The DPOA stated they did not recall checking the storage unit. No missing art pieces were found in the room.

The DPOA stated that R1 had a history of hiding items and had been treated by a neurologist for paranoia and high levels of anxiety, which contributed to hoarding and hiding behaviors. R1 insisted that the four art pieces had been hidden very well in the closet.

ED stated that R1 believed that a staff member had taken the art pieces while R1 was out of the room, particularly in May 2025, when the flooring in R1’s room was being replaced and R1 temporarily stayed in a nearby room. R1 stated it must have been a woman, but could not identify who.

Continued on LIC-809C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2025
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: 07/31/2025
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ED reassured R1 that staff had not touched anything in the closet and had not replaced the flooring under the closet. ED requested permission from both R1 and the DPOA for staff to search the room for the missing art pieces, and both agreed. After the meeting, staff searched the room but did not locate the missing art pieces. ED informed R1 and the DPOA that the police would be contacted to report the incident as a theft and loss, and they agreed. ED stated that R1 had expressed multiple times that they were satisfied with the investigation conducted regarding the missing art pieces and felt safe residing at the facility. The DPOA stated that the facility remained the appropriate place for R1 and confirmed that they would be the only person to move any items from R1’s room.

ED contacted the police and was advised that, due to a lack of evidence, the incident should be filed online. ED submitted the report online, provided R1 with a copy of the police report and case number, and informed DPOA that R1 had a hard copy. ED also filed reports with the Ombudsman and CDSS.

ED stated that an in-service training was conducted with staff regarding residents’ rights, property protection, respecting personal space and belongings during care tasks, and elder abuse prevention.

ED documented that R1 had waived declaring personal items on the inventory list at the time of admission. Theft and loss records were logged on LIC 9060.

LPA reviewed R1’s LIC 602 Physician’s Report, Needs and Services Plan, and LIC 621 Resident Personal Property and Valuables (SPV) form. LPA observed that no personal property or valuable items were declared; the form was crossed out with “N/A” written and signed by R1.

LPA attempted to visit R1's room but caregivers were in the middle of assisting R1 in the transfer to the bathroom for toileting and showering.

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: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC809 (FAS) - (06/04)
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