435202819-3-7-2025-26-AS-KHOS-DEXQPE-20250320122037

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202819
Report Date: 03/07/2025
Date Signed: 03/07/2025 04:51:02 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/21/2022 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20220721135927

FACILITY NAME:	PALO ALTO COMMONS		FACILITY NUMBER:	435202819
ADMINISTRATOR:	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: 185	DATE:	03/07/2025
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Li Li		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident's hygiene needs are not being met.
Staff not changing resident's diaper.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Administrator Li Li. On 07/21/2022, the Department received a complaint with the above allegations. On 07/27/2022, LPA Marrufo conducted an initial complaint investigation visit.

Resident R1’s Resident Assessment dated 03/30/2022 states, “PCA [Personal Care Attendant] does everything for [R1] grooming, dressing, and brushing teeth…PCA full assist in dressing, grooming, and brushing teeth.” R1’s Resident Assessment also states, “PCA does full assist for toileting. Incontinent products supplied by Hospice. Checking on [R1] every shift.”

During the visit on 07/27/2022, LPA Marrufo toured resident R1’s living unit and interviewed R1. LPA observed that R1’s bathroom contained a toothbrush, toothpaste, and floss. LPA observed there to be a supply of diapers and wipes in R1’s living unit. During interview, R1 stated that R1 brushes R1’s own teeth. R1 stated staff remind R1 to brush R1’s teeth. See LIC9099-C pages for more information. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 26-AS-20220721135927

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/07/2025

NARRATIVE

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During visit on 03/07/2025, LPA Marrufo interviewed staff S1 and S2. Both S1 and S2 stated to have provided care to R1. Both S1 and S2 stated to have observed R1 begin to lose teeth. S1 stated that S1 provided care for R1 including bathing, toileting, and brushing R1’s teeth. S1 stated S1 would apply toothpaste to R1’s toothbrush and brush R1’s teeth up and down and side to side and would also brush R1’s molars. S1 stated S1 would have R1 spit out the toothpaste and rinse with mouthwash and spit out the mouthwash. S1 stated the bottle of mouthwash was stored in a locked cabinet in R1’s room and S1 would unlock the mouthwash with a key. S1 stated S1 would floss R1’s teeth. S1 stated to have worked from 6:00 AM to 2:00 PM each day. S1 stated to have assisted R1 with brushing R1’s teeth and maintaining R1’s dental hygiene each morning and afternoon. S1 stated that when S1 arrived at 6:00 AM, S1 would observe that R1’s teeth were clean. S1 stated to have never arrived at the beginning of a shift and observed any signs that R1’s teeth had not been cleaned by the staff of the prior shift. S1 stated to have never observed food in R1’s mouth or on R1’s teeth at the beginning of S1’s shift when S1 would brush R1’s teeth.

S1 stated that S1 would change R1’s diapers any time R1’s diapers became soiled. S1 stated to have changed R1’s diapers as needed, which was usually once every hour. S1 stated to have changed R1’s diaper and cleaned R1’s private areas with wipes.

S2 stated to have assisted R1 with brushing R1’s teeth and with changing R1’s diapers. S2 stated that R1 would close R1’s mouth while S2 was brushing R1’s teeth, making it difficult for S2 to brush all R1’s teeth. S2 stated R1 would not let S2 use floss to clean R1’s teeth. S2 stated to not remember if S2 used mouth wash with R1. S2 stated to have never noticed anything that would make S2 think that the staff on the prior shift did not brush R1’s teeth.

S2 stated to have changed R1’s diapers once every two hours. S2 stated to have used wipes and cream to clean R1’s private area while changing R1 into new diapers. S2 stated to have never observed any indication that the staff from the prior shift had not changed R1’s diapers.

Both S1 and S2 stated to have never observed R1 to have a shortage of diapers.

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SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20220721135927

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/07/2025

NARRATIVE

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During interview on 03/07/2025, Administrator (ADM) Li Li stated that R1 did not like having staff brush R1’s teeth or touching R1. ADM stated that R1 had incidents of biting the staff when staff attempted to brush R1’s teeth. ADM stated to have spoken with R1’s family about R1 biting staff when staff were attempting to brush R1. ADM stated that ADM worked with staff to find the right time to have staff brush R1’s teeth. ADM stated to have worked with staff to have R1 rinse R1’s mouth with water after every meal. ADM stated to have had training with staff to address R1’s challenges with personal hygiene and oral care. ADM stated that staff regularly changed R1’s diapers and there was always a supply of new diapers available for R1.

LPA Marrufo obtained a copy of the following training logs: Personal Care/W2/Oral Care, dated 02/18/2022; Mouth Care/Personal care/Refused Showers dated 06/13/2022; and Personal Care/Oral Care, dated 07/29/2022.

Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22

This report was reviewed with Administrator Li Li and a copy of this report was provided.

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END REPORT

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC9099 (FAS) - (06/04)

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