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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202819
Report Date: 07/26/2023
Date Signed: 07/26/2023 03:43:01 PM


Document Has Been Signed on 07/26/2023 03:43 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: 174DATE:
07/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Li LiTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator (ADM) Li Li. The purpose of the visit was to inquire about an incident self-reported by the facility on an Unusual Incident/Injury Report on 06/12/2023. The Incident Report stated that on 05/29/2023, a resident's bicycle was stolen at the facility.

The Incident Report states that facility camera footage showed two individuals, one male and one female, broke through the garage gate door and stole the resident's bicycle. The facility filed a police report with local police department.

During visit, LPA Marrufo interviewed ADM. ADM stated that the camera footage showed the two individuals had something in their hands and were working on the lock. ADM stated that after the bicycle theft occurred, alarms were installed on the gate door that would sound an alarm and alert staff that the door had been opened. LPA Marrufo obtained copies of the resident's theft and loss record that recorded the stolen bicycle and a copy of the in-service training ADM conducted with staff to address the facility theft and loss policy.

LPA Marrufo observed the gate door during visit. Facility staff triggered the alarm to demonstrate that the alarm works. LPA Marrufo observed a sound alarm and visual alarm on the door when it was opened.

No deficiencies were cited as per California Code of Regulations Title 22.

This report was reviewed with ADM 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: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
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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