435202819-5-6-2025-26-AS-KHOS-DH2JGL-20250526070231

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202819
Report Date: 05/06/2025
Date Signed: 05/06/2025 12:43:48 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
09/27/2022 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20220927080512

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: 184	DATE:	05/06/2025
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Li Li		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff hit resident in care
Residents sustained injuries while in care because staff are not providing proper transfer assistance
Staff are not mitigating the cockroach infestation at the facility

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 09/27/2022, the department received a complaint with the above allegations. On 10/05/2022, LPA Marrufo conducted an initial complaint investigation visit. On 03/07/2025, LPA Marrufo conducted an additional complaint investigation visit.

During visit on 10/05/2022, LPA Marrufo was not able to find and interview resident R1 at the facility.

During visit on 10/05/2022, LPA Marrufo interviewed residents R2-R7. R2 and R5 stated to have never been hit by staff. R3 stated to have never been hit by a staff, but observed a staff hit another resident. R3 was not able to tell the name of the resident whom he/she observed a staff to have hit or the name of the staff whom he/she observed hit a resident. R4, R6, and R7 were not able to respond to LPAs questions.

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: 05/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025

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-20220927080512

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: 05/06/2025

NARRATIVE

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During interview on 05/06/2025, S6 stated to have never observed staff not providing proper transfer assistance to residents, to have never observed a resident being injured because staff improperly transferred them, and to have not observed a resident requiring two staff to transfer him/her being transferred by only one staff.

During visit on 05/06/2025, LPA Marrufo reviewed the resident records of R2-R9 and did not find any documents, including hospital discharge records or incident reports, related to injuries due to staff not providing proper transfer assistance. There were no resident records that matched the name of R1.

LPA Marrufo obtained copies of pest control invoices from every month between 02/02/2022 to 08/23/2022. The pest control invoices indicate pest control was done against cockroaches.

During interviews on 10/05/2022, R2, R3, and R5 stated to have observed there to be cockroaches at the facility. R4 stated to have not observed there to be cockroaches at the facility. R6 and R7 were not able to respond to LPA Marrufo’s questions.

During interviews on 03/07/2025, S2 stated to have observed cockroaches at the facility. S3-S5 stated to have not observed cockroaches at the facility.

Based on information from interviews conducted with staff and residents, 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 were cited under California Code of Regulations Title 22.

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

Page 3 of 3.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 26-AS-20220927080512

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: 05/06/2025

NARRATIVE

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On 03/07/2025, LPA Marrufo obtained a copy of the facility Rent Roll from 09/30/2022 and a screenshot of the Resident Record Database System. The Rent Roll did not have R1’s name in the record of residents who were paying rent during the month of 09/2022. The screenshot of the Resident Record Database System indicated that there were no search results when R1’s name was searched.

On 03/07/2025, LPA Marrufo obtained a copy of an email thread between facility managers sent on 11/30/2022. The email thread stated staff S1 was Employee of the Month during one of the months of 2022 and was nominated as Employee of the Year for 2022.

On 03/07/2025, LPA Marrufo interviewed S2-S5. S2-S5 stated to have not known R1 and to have not observed S1 hit a resident.

During visit on 05/06/2025, LPA Marrufo interviewed S6, the facility HR Director. S6 stated that as HR Director, he/she is available to discuss with staff any concerns they may have about other staff. S6 started to have not received any report that S1 hit R1 or any other residents at the facility.

On 10/05/2022, LPA Marrufo obtained Inservice Sign In Sheets from the following dates and topics: 03/25/2022, Transferring from Wheelchair to Chair; 06/10/2022, Hoyer/Stand Lift, 07/14/2022, Transition from Hoyer Lift to No Machine (only 1 or 2 Person Assist); 08/08/2022, Stand Up Lift Training; 08/15/2022, Hoyer Lift.

During interviews on 10/05/2022, S2-S5 stated to have been injured while staff were assisting them during transferring. S6 and S7 were not able to respond to LPA Marrufo’s questions.

During interviews on 03/07/2025, S2-S5 stated to have never observed staff not providing proper transfer assistance to residents, to have never observed a resident being injured because staff improperly transferred them, and to have not observed a resident requiring two staff to transfer him/her being transferred by only one staff.

Page 2 of 3.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025

LIC9099 (FAS) - (06/04)

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