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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202819
Report Date: 05/23/2024
Date Signed: 05/23/2024 12:33:23 PM


Document Has Been Signed on 05/23/2024 12:33 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: 180DATE:
05/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Li LiTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator Li Li. The purpose of the visit was to address an incident self-reported by the facility via LIC624 Unusual Incident/Injury Report form and SOC341 Suspected Elderly/Adult Abuse Form on 02/20/2024. The reported incident occurred on 02/12/2024 and involved a private duty care giver in the independent living section of the facility who drove an independent living resident whom the private care giver was not contracted with to a bank. At the bank, the independent living resident withdrew $6,500.

During visit, LPA Marrufo interviewed Administrator Li Li and 8 independent living residents. During interview, Administrator Li Li stated the private care giver admitted to driving the independent living resident out of the building and to a bank and to receiving $200 from the resident as a gift. The rest of the $6,300 is currently missing and unaccounted for, according to the resident's Financial Power of Attorney.

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 this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
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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