435202819-3-27-2025-26-AS-KJAN-DF6SPT-20250327140341

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202819
Report Date: 03/27/2025
Date Signed: 03/27/2025 02:04:03 PM

Document Has Been Signed on 03/27/2025 02:04 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: 186	DATE:	03/27/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:55 AM
MET WITH:	Patricia Oliver and Diana Smith		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

NARRATIVE

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On March 27, 2025, at 8:55 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident visit regarding an incident that occurred on 03/19/2025 when the resident (R1) was given a PRN as needed medication by mistake. Upon arrival, the LPA was greeted by the Health and Wellness Director (HWD), Patricia Oliver and Business Office Director (BOD), Diana Smith. The LPA disclosed the purpose of the visit.

LPA interviewed one (1) resident (R1) and four (4) staff members: Executive Director (ED), Health and Wellness Director (HWD), Medication Technician (S1) and LVN Community Nurse (S2).

HWD stated that on 03/19/2025, R1 was given ‘Labetalol,’ a medication that was ordered as needed. R1 knew their medications well and told the Med Tech that they were not supposed to have the medication unless there was a specific need for it and R1 said they should not have received this medication. HWD stated that S1 did not read or recognize the medication order on the QMAR as an as-needed order, and R1 was concerned about having received the wrong medication. HWD stated that R1 had been diagnosed with Parkinson’s and was receiving care in the elite care unit following their return from the hospital for a UTI. R1 had been alert and oriented. HWD mentioned that S1 had reached out to S2, who then performed a bedside assessment of R1. S2 called and faxed R1’s PCP regarding the medication error and received instructions from the PCP on the care plan in response to the error. HWD stated that the facility held a care conference call with R1’s family to explain how the medication error occurred and what actions the facility was taking to prevent similar errors in the future.

Continued on LIC-809C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

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: 03/27/2025

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ED stated that S1 had administered ‘Labetalol,’ a PRN medication, thinking it was a routine medication. The medication was supposed to be given only as needed, after checking the blood pressure and confirming it met certain parameters. R1 took the medication and asked S1 which medications had been given. S1 and R1 both realized at the same time that the wrong medication had been administered. R1 remained stable and experienced with no side effects. S2 reached out to R1’s PCP regarding the medication error. ED stated that they had conducted a Zoom meeting with R1’s family on the same day. ED stated that S1 had been working at the facility for a long time and was a very good med tech who cared deeply for the residents.

S1 stated that on 03/19/2025, they had given R1 their morning medications at 8:30 AM. The ‘Labetalol’ PRN medication had appeared as a routine medication in the QMAR. The medication was supposed to be administered only if R1’s blood pressure exceeded the specified parameter. S1 stated that R1’s blood pressure had been below that parameter, but they had still administered the medication. They acknowledged it was their error. After checking the QMAR, they realized the parameter did not support giving the medication. S1 stated that R1 had asked for the names of the medications given to them but had not said anything about why the ‘Labetalol’ had been administered.

S2 stated that the ‘Labetalol’ medication had been set as a routine medication in the QMAR but included a parameter indicating it should be given only if the blood pressure exceeded a certain threshold. R1 had moved to the elite care unit on 03/13/2025 or 03/14/2025. S2 stated that S1 had called them, and S2 had informed R1 that the ‘Labetalol’ had been administered in error. S2 stated that R1 appeared anxious but not visibly upset. S2 performed a blood pressure reading and asked R1 how they were feeling. S2 called R1’s PCP, reported the medication error, and coordinated with the PCP regarding R1’s care plan following the error.

R1 stated that they were aware of the medication error involving ‘Labetalol’ and knew which medications they were supposed to be taking, as they always asked. R1 stated that the facility had categorized ‘Labetalol’ as a routine medication. R1 also stated that some individuals at the facility did not know the purpose behind certain medications. These individuals were new and only knew the quantity of medications to administer. R1 stated that their blood pressure was highly variable and that they had other conditions that put them at high risk for stroke, making such medication errors potentially life-threatening. R1 stated that they could not remember how they felt on the specific day the ‘Labetalol’ was given in error; they generally felt tired and lethargic but had no recollection of that particular day.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

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: 03/27/2025

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R1 stated that similar errors had occurred in the past at the Commons. Staff did not understand the doctor’s order and used their own interpretation instead of contacting the doctor for clarification, which was not how the doctor intended the medication to be used. R1 stated that they felt additional staff training, increased supervision, more managerial oversight, and frequent evaluations of medication administration practices at Commons could help prevent such errors.

LPA reviewed R1’s hospital discharge notice, dated 03/13/2025, which indicated to administer one ‘Labetalol’ as needed for SBP >170 or DBP >105.

LPA reviewed R1’s vital signs record. The blood pressure reading taken at 8:43 AM on 03/19/2025 showed reading written as 146/90.

LPA reviewed R1's Medication Administration Record (MAR). The 'Labetalol' 100 MG medication was listed as needed for SBP>170, DBP>105.

LPA reviewed R1's Centrally Stored Medication Records, which showed Labetalol' medication listed with instructions "Take 1/2 tablet (50 MG) as needed SBP>170, DBP>105.

LPA reviewed the faxed note sent to R1’s doctor indicating that a medication error had occurred. R1 had been given ‘Labetalol’ 50 mg despite a blood pressure reading of 146/90.

A deficiency was cited based on LPA observations, record reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, and Plans of Correction were reviewed and developed with the Business Office Director. A copy of this report and appeal rights were discussed and provided to the Business Office Director, Diana Smith, whose signature on this form confirms receipt of these documents.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/27/2025 02:04 PM - It Cannot Be Edited

Created By: Kiran Jain On 03/27/2025 at 01:30 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/27/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/28/2025 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (c) If the resident's physician has stated…facility staff designated… (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Business Office Director will develop a plan to ensure correct medications ordered by physician are always given to the residents. The Business Office Director will provide a copy of the plan to CCLD by 03/28/2025.
	8 9 10 11 12 13 14	Based on observations, interviews, and records review, the facility staff did not ensure R1 was given the prescribed PRN medication according to the physician's directions, which posed an immediate health, safety, or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	April Cowan
NAME OF LICENSING PROGRAM MANAGER:

	Kiran Jain
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

LIC809 (FAS) - (06/04)

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