On 12/24/2024, LPA reviewed the facility’s Staff Roster and noted that the care nurse's (GCM) name was not listed on the staff roster. LPA reviewed the facility’s Resident Roster and observed that R2’s name and room number were listed on the roster. LPA reviewed R2’s LIC 601 Identification and Emergency Information form and noticed that GCM’s name was listed under the placement agency and as an emergency contact (friend). The LIC 601 form had been completed and signed by GCM on 09/04/2024, with GCM's title written as "Geriatric Care Manager" on the form. From R2’s LIC 601 form review, LPA obtained the contact information for R2’s Family Member (FM1), Persons Responsible for Financial Affairs (FRP1 and FRP2), and Primary Care Physician (PCP2).

On 12/24/2024, LPA reviewed R2’s LIC 602 Physician’s Report, dated 09/19/2024, which stated R2’s primary diagnosis as Dementia with behavioral disturbances. LPA reviewed R2’s LIC 603 Preplacement Appraisal Information form, which had been completed and signed by GCM on 09/03/2024.

On 01/03/2025, LPA interviewed R2’s Fiduciary/Trustee/Financial Responsible Persons (FRP1 and FRP2). FRP1 and FRP2 stated they had been brought in by R2’s attorneys as co-trustees and had paid R2’s bills while ensuring R2’s needs were met. FRP1 and FRP2 stated that R2’s Family Member (FM1) had been the decision-maker and that the care manager (GCM) had advised FM1 regarding R2’s care. FRP1 and FRP2 stated that the decision to move R2 to the memory care facility had been made between FM1 and GCM.

On 01/03/2025, LPA interviewed Family Member (FM1), who stated that R2 had been moved to the facility around August or September 2024. FM1 stated that FRP1 and FRP2 had mentioned to them that R2 would not have enough money left for at-home care and that GCM, who had been hired by FRP1 and FRP2, had proposed that R2 be moved to a memory care facility due to Dementia. FM1 agreed, as this ensured R2’s money would not run out and R2 would receive proper care at the facility. FM1 stated they had tried and done their best in R2’s interest. FM1 stated that R2’s previous tenant (FTE), who had also been listed in R2’s will and had been R2’s POA, then had declined to continue as R2’s POA and FTE hired FRP1 and FRP2 to manage R2’s finances. FM1 stated that R2’s dementia had been slowly progressing since 2015.

Continued on 9099-C

On 01/03/2025, LPA interviewed R2’s former Primary Care Physician’s office (PCP2). PCP2 stated that R2 was no longer a patient at their clinic and that their office had been notified by R2 that they no longer needed a Primary Care Physician from their office.

On 01/07/2025, LPA interviewed R2’s former tenant (FTE), who stated that they had been a good friend of R2, had worked as R2’s bookkeeper, and had assisted with R2’s finances. FTE mentioned that, before 2015, they had lived in R2’s house as a tenant and had been added to R2’s will around April 2019, prior to R2 being diagnosed with dementia. FTE stated they had sold R2’s properties at the end of 2021 or early 2022 to help R2 financially. FTE further stated that R2 had been diagnosed with dementia in January 2022 and that R2’s physician (PCP2) had provided a letter confirming the diagnosis at that time. In 2022, FTE stated they had hired fiduciaries (FRP1 and FRP2) to manage R2’s affairs. After that, FTE lost contact with R2 and believed R2 continued to live in the same house.

On 01/08/2025, LPA interviewed R2’s Geriatric Care Manager (GCM). GCM stated they work for a private company and were taking care of R2, coordinating with R2’s POA (FM1) and Fiduciary (FRP1 and FRP2). GCM stated R2 had advanced dementia, refused essential care services at home, and would wander at streets. POA made the decision to move R2 to memory care. GCM stated FM1 hired the fiduciary (FRP1 and FRP2), and GCM were hired by both FM1 and the fiduciary about 1 year ago. GCM stated they changed R2’s primary care physician to PCP1 as R2’s former PCP (PCP2) was out of the county when R2 needed to move to the facility. GCM stated R2 was diagnosed with dementia back in 2011, but are not sure, since they don’t have R2’s chart in front of them, and R2’s physician had written a letter indicating R2 didn’t have the mental capacity to make decisions. GCM stated that based on their guess this letter was written around 2011 or a bit later in 2018. FM1 had this letter and POA was invoked after that. GCM stated that R2 was moved to the Palo Alto Commons facility in December 2024, and initially, R2 sometimes packed their stuff to leave the facility and walked towards the door, but never walked out the door. GCM stated that R2 was now calm and happy at the facility.

Continued on 9099-C

On 01/15/2025, LPA interviewed the facility’s Executive Director (ED), who stated that R2 had not been held at the facility against their will. Initially, R2 had been unhappy upon entering the facility, but R2 was happy now, hugged caregivers, and enjoyed the food. R2 had made friends, was more relaxed, and had not been agitated. R2’s POA had initiated the move to the facility due to concerns about R2's safety at home, including wandering issues and dementia, as well as the challenges caregivers faced in meeting R2’s care needs at home. The ED explained that the facility had used a mobile concierge service to assess R2 and complete licensing forms, as R2’s needs were urgent for the placement. The ED also stated that they were unaware that R2’s primary care provider (PCP) had not been informed about R2’s move to the facility. Furthermore, the ED confirmed that R2 was free to move around the facility and had never been restrained by any caregiver.

On 01/15/2025, LPA interviewed Resident (R2), who stated that they liked the facility but did not want to live there permanently, as they were temporarily staying at the facility for one week. R2 mentioned that they liked their home but could not remember how long they had lived there. R2 also stated that they had recently met the facility's caregivers and liked them.

Based on records reviewed and interviews conducted, it was determined that the care nurse (GCM) was not an employee of the Palo Alto Commons facility. GCM was identified as a Geriatric Care Manager employed by a private company. The department has determined that the allegation is false, could not have happened, and/or is without a reasonable basis. Therefore, the allegation is UNFOUNDED.

No deficiencies were cited under the California Code of Regulations, Title 22.

An exit interview was conducted. A copy of this report was discussed and left with the Executive Director, Li Li, whose signature on this form confirms receipt of this report.