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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202819
Report Date: 05/15/2023
Date Signed: 05/15/2023 04:06:00 PM


Document Has Been Signed on 05/15/2023 04:06 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:LI LIFACILITY TYPE:
740
ADDRESS:4075 EL CAMINO WAYTELEPHONE:
(650) 494-0760
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:250CENSUS: 187DATE:
05/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Li LiTIME COMPLETED:
04:15 PM
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 Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator Li Li. The Case Management visit was in response to an incident involving resident R1 leaving the facility without supervision on 03/22/2023 and reported by the facility via Unusual Injury/Incident Report on 03/24/2023.

During visit, LPA Marrufo obtained copies of R1's records and staff records. R1's Physician's Report states R1 has dementia and is unable to leave the facility unassisted. R1's updated Resident Assessment states that R1 is to be escorted to all meals and staff are to conduct nightly checks. The facility assignment log for PM shift states orders to conduct safety checks every 2 hours. The assignment log for Noc Shift includes orders to conduct safety checks on R1 at 1 AM, 3 AM, and 6 AM. LPA Marrufo obtained a copy of the In-Service Elopement training that was conducted on 04/05/2023.

LPA Marrufo interviewed staff S1-S3, who stated that they conduct safety checks on R1 every 2 hours and escort R1 to breakfast and lunch.

An Advisory Note was issued. See LIC9102 for more information. No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Administrator Li Li and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023
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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