<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202819
Report Date: 11/12/2024
Date Signed: 11/12/2024 01:08:45 PM

Document Has Been Signed on 11/12/2024 01:08 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 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: 190DATE:
11/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Patricia Oliver and Li LiTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/12/2024, Licensing Program Analyst (LPA) Kiran Jain conducted an unannounced case management visit to follow up regarding an incident that occurred on 11/04/2024 where resident (R1) eloped from the facility after attending a birthday concert at the facility’s great room. LPA Jain met with Executive Director, Li Li and explained the purpose of the visit.

On 11/04/2024, R1 eloped from the facility around 3:35 PM during a birthday concert unsupervised. R1 was observed to be eating cake in the great room around 3:30 PM. R1 was stopped by the owner of a martial arts studio down the street from the facility and the studio owner called 911. EMT called the facility to let them know on R1’s condition and location.

Based on the interview conducted with Executive Director (ED), ED stated R1 was at a birthday party celebration in the great room from 2:30 PM to 3:30 PM and there were about 20 residents, and 2 activities assistant staff members present during the birthday concert event. After the event, R1 got up and walked back to their room on their own. R1 then came back out to the living room from their room and wandered out by walking out of the front door of the facility without notifying anyone. No one witnessed that. R1 walked into a local shop and said that they are local and are very tired. Shop owner was surprised to see an elderly in distress breathing heavily and called 911. EMT called facility to notify about R1’s location. Facility staff members went down the street to pick up R1. When staff arrived, R1 was sitting on a bench and answering questions with EMTs. Staff members recommended to send R1 to the Hospital for further evaluation and observations. ED stated R1 is high functioning, walks with a walker, never showed any wander behaviors prior to the incident. ED stated that R1 is part of Elite care in Assisted Living, where there are 7 staff members to take care of 24 residents.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: 11/12/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on the review of R1’s Physician’s Report (LIC 602) dated 06/08/2023, R1 has a primary diagnosis of Dementia, is non-ambulatory due to mental condition and deemed not able to leave the facility unassisted. The facility staff failed to ensure that R1 doesn’t leave the facility unassisted, which posed an immediate health, safety or personal rights risk to persons in care.

Based on the review of R1’s Resident Assessment Results done on 03/01/2024, R1 needs to be provided staff escort to and from the activities. The facility staff failed to ensure R1 is provided escort after attending an activity inside the facility, which posed an immediate health, safety or personal rights risk to persons in care.

LPA Jain conducted additional staff interview with S1 and reviewed additional documents - R1’s Progress notes, Activity Staff schedules, and in service all staff training for Elopement policy and procedures.

A deficiency was cited under the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. See LIC 809-D page for more information.

An immediate civil penalty of $500.00 was assessed today for the Absence of Supervision, which resulted in R1’s eloping from the facility. Failure to correct the deficiency may result in additional civil penalties.

This report was reviewed with Executive Director, Li Li and a copy of this report along with the appeal rights was provided. A copy of the civil penalty was also provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/12/2024 01:08 PM - It Cannot Be Edited


Created By: Kiran Jain On 11/12/2024 at 12:13 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: 11/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/12/2024
Section Cited
CCR
87411(a)

1
2
3
4
5
6
7
Personnel Requirements - General
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This was not met as evidence by:
1
2
3
4
5
6
7
The Executive Director will develop a plan to ensure residents are being supervised at all times. Exectuive Director will provide a copy of the plan to CCL by 11/12/24.
8
9
10
11
12
13
14
The facility staff failed to prevent resident (R1) from eloping the facility on 11/04/2024. R1 has dementia, is non-ambulatory due to mental condition, deemed not able to leave the facility unassisted, and was able to leave facility unassisted by the scheduled staff on 11/04/2024, which posed an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Immediate Civil Penalty of $500.00 is being assessed today 11/12/24 for the absence of supervision.

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.
SUPERVISOR'S NAME:April Cowan
LICENSING EVALUATOR NAME:Kiran Jain
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3