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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202819
Report Date: 06/13/2024
Date Signed: 06/13/2024 01:00:15 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/13/2024 01:00 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: 104DATE:
06/13/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Li LiTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Annual Continuation Visit and met with Administrator Li Li.

During visit, LPA Marrufo reviewed the Centrally Stored Medication and Destruction Records for 7 residents and found them to be complete. LPA Marrufo reviewed 7 resident records and 7 staff records and found them to be complete.

LPA Marrufo toured 7 resident living units and observed the living units to have functioning lights and available bedding and clothing storage areas. LPA Marrufo toured 7 bathrooms and observed each bathroom to have water temperatures between 107 F and 115 F. Each bathroom had available soap and paper towels and working lights.

LPA Marrufo toured the outside areas and found them to be clear of obstructions.

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: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
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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