Palo Alto Commons

Type of visit: Case Management - Other

On 9/16/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct a Case Management follow up in regards to an exclusion that took effect on 9/10/2026. According to the Administrator/Executive Director, Li Li, S1 has never worked at the facility and is not currently on their staff schedule. During the visit, LPA Calandra requested and received a copy of the facility's current LIC 500 and staff schedule for the month of September. No deficiencies cited during today's visit. An exit interview was conducted and a copy of the report provided to the facility representative via email.the state’s words, verbatim · CDSS document, Sep 16, 2026

Type of visit: Case Management - Other

On 8/4/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to follow up on a incident that occurred the same day in which a small fire started in the facility. LPA Calandra was greeted by Li Li, Executive Director and explained the purpose of the visit. On 8/4/2026, a light in R1's broke causing a small fire in the bathroom of the apartment. According to the Administrator, the resident was not in their room at the time and a staff member passing by grabbed a fire extinguisher which they used to extinguish the fire. The fire department was contacted promptly and a fire marshal came to the facility to evaluate the facility. According to the fire marshal, the building is structurally safe. No residents were evacuated from the facility and no injuries occurred from this incident. LPA requested that when the fire inspection report is available that a copy be sent to the Department. No deficiencies cited during today's visit. An exit interview was conducted and a copy of this report emailed to the facility representative.the state’s words, verbatim · CDSS document, Aug 4, 2026

Type of visit: Required - 1 Year

On 56/1/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Jenny Huynh, Assistant Executive Director and explained the purpose of the visit. Li Li, Executive Director arrived later during the visit. LPA toured the physical plant. The facility consists of 2 buildings with 3 floors in each. Assisted Living and Memory Care is in one building and Independent Living is in the other. LPA inspected 10% of rooms at random. All bedrooms had the required furniture and sufficient lighting. All bathrooms had anti-skid flooring and grab bars. The facility's hot water temperature was measured within the required 105-120 degrees Fahrenheit. The facility's fire alarm and carbon monoxide detectors were observed to be operating properly. The facility's fire extinguishers were last checked on 12/3/2025 and all were observed to be fully charged. The facility had the required 7 days of non perishables and 2 days of perishables on site. No food was expired. The facility's first aid kit was observed to have all of the required items. All sharp objects, soap, detergents, and poisons were observed to be locked and in-accessible to persons in care. During the visit LPA collected the following document: Current Liability Insurance and LIC 500 Personnel Summary Report. LPA reviewed 5 resident files and 6 staff files. All were observed to be complete. This facility does not handle cash resources for residents. A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records kept at the facility. No deficiencies cited during today's visit. An exit interview was conducted and a copy of the report provided to the facility representative.the state’s words, verbatim · CDSS document, Jun 1, 2026

Type of visit: Case Management - Incident

On January 8, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to follow-up on an incident that was reported by the facility. LPA met with the administrator and explained the purpose of today's visit. On December 19. 2025, CCL received a report of suspected dependent adult/elder abuse via SOC 341 concerning resident #1 (R1). The report indicated on December 14, 2025, R1 called the police reporting a male staff #1 (S1) "man handled" R1 while providing care. During today's visit, LPA attempted to interview R1 but R1 was out of the facility. LPA interviewed the administrator and the assistant administrator who stated R1 is alert but has a lot of confusion. They stated that R1 preferred female caregivers and they do honored this preference but when there was no female caregivers available to answer R1's call bell because they were on their breaks or assisting other residents, then they would give R1 a choice either to be assisted by a male caregiver or wait for a female caregiver became available. They stated that S1 has been working at the facility for a couple of years and they have not gotten any complaints about S1's work performance. The administrator and the assistant administrator reported after R1 reported the incident, they removed S1 from caring for R1 and R1 was offered to be cared for by the nurse. They stated that the police officer came, interviewed R1 and closed the case as there was no evidence of elder abuse occurred. LPA interviewed facility staff and they validated the information that was provided by the administrator and the assistant administrator. They also stated that R1 tends to threaten facility staff that he/she would call the police if he/she did not get their way. Based on documents provided, LPA observed that the assistant administrator spoke with R1 after the incident and R1 agreed that when a female staff was not available, he/she would either wait until someone is available or allow a male caregiver to assist. No deficiency is cited today. This report is reviewed and discussed with the administrator and the asst administrator. A copy is provided.the state’s words, verbatim · CDSS document, Jan 8, 2026

Type of visit: Case Management - Incident

On 12/09/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management regarding an incident report received on 12/05/2025 regarding a resident missing jewelry. LPA met with the assistant executive director Jenny Huynh. On 12/04/2025, it was reported to staff by the POA of R1 that there was missing jewelry observed from the resident's safe. According to staff, the POA was the one that observed the open safe and missing jewelry. Staff reported on 12/05/2025 to the Department of the missing jewelry via incident and SOC341 with unknown suspect. The same day the facility reported to the Palo Alto Police Department and they conducted a preliminary investigation and assigned a case number. According to the facility staff, staff such as the housekeeper and two caregivers were interviewed but there were no immediate findings. In response to the incident, the facility conducted an in service training regarding theft and loss on 12/05/2025. LPA received a copy of the in service training. No citations issued. Report is reviewed assistant executive director and copy.the state’s words, verbatim · CDSS document, Dec 9, 2025

Type of visit: Case Management - Incident

On 11/25/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - incident report visit. LPA met with the executive director Li Li and explained the purpose of today's visit. On 11/20/2025 the Department received an incident report regarding R1 had a fall in their room in which they sustained a laceration on the left eye brow with the complaint of dizziness and pain. The resident was getting up to go and use the restroom without assistance from staff. This incident occurred on 11/18/2025 around 5pm. The resident was sent to the hospital where they received stitches to help heal the injury. The resident returned the next day on 11/19/2025 at approximately 1:40am. The resident did not suffer from any broken bones or other injuries besides the laceration. The resident's care plan and diagnosis is discussed with Li Li. The resident receives a high level of supervision regularly as part of the care plan, which includes assistance to the restroom due to their diagnosis and cognitive condition. Discharge instructions from the hospital was followed and no new conditions developed. Resident has not had any other falls since this incident. LPA discussed care plans and received a copy of the resident's care plan and physicians report. No citations issued. Report is discussed and a copy is provided to the executive director.the state’s words, verbatim · CDSS document, Nov 25, 2025

Type of visit: Case Management - Other

LPA Jeung met with health and wellness director in the absence of executive director and business office director, to inquire about the employment status of staff #1. LPA spoke with executive director Li Li by phone, who stated that she was not familiar with the name of staff #1. She will review her payroll and contact LPA within 24 hours to provide employment status of staff #1. No deficiencies cited today.the state’s words, verbatim · CDSS document, Oct 22, 2025

Type of visit: Case Management - Incident

On July 31, 2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident inspection visit regarding a reported Theft and Loss incident that occurred on 07/17/2025. The facility also reported SOC 341 for the same Theft and Loss incident. Upon arrival, the LPA met with the Executive Director (ED), Li Li and disclosed the purpose of the visit. The ED informed the LPA that the total facility census was 184. ED stated that during a care conference, R1 reported that four art pieces were missing. These pieces were originally stored in R1’s closet, wrapped in a blanket. They were only paper art pieces and had not yet been placed in frames. The DPOA, who attended the meeting, brought copies of similar art pieces to show, but they were not the original items. The DPOA stated that R1 purchased the art pieces at a street fair for $40 each, totaling $160 for all four pieces. The ED asked the DPOA if they had thoroughly searched R1’s room, and the DPOA confirmed that they had. ED also asked if the large off-site storage unit rented by R1 had been checked, as the DPOA frequently moved R1’s belongings between the room and the storage space. The DPOA stated they did not recall checking the storage unit. No missing art pieces were found in the room. The DPOA stated that R1 had a history of hiding items and had been treated by a neurologist for paranoia and high levels of anxiety, which contributed to hoarding and hiding behaviors. R1 insisted that the four art pieces had been hidden very well in the closet. ED stated that R1 believed that a staff member had taken the art pieces while R1 was out of the room, particularly in May 2025, when the flooring in R1’s room was being replaced and R1 temporarily stayed in a nearby room. R1 stated it must have been a woman, but could not identify who. Continued on LIC-809C ED reassured R1 that staff had not touched anything in the closet and had not replaced the flooring under the closet. ED requested permission from both R1 and the DPOA for staff to search the room for the missing art pieces, and both agreed. After the meeting, staff searched the room but did not locate the missing art pieces. ED informed R1 and the DPOA that the police would be contacted to report the incident as a theft and loss, and they agreed. ED stated that R1 had expressed multiple times that they were satisfied with the investigation conducted regarding the missing art pieces and felt safe residing at the facility. The DPOA stated that the facility remained the appropriate place for R1 and confirmed that they would be the only person to move any items from R1’s room. ED contacted the police and was advised that, due to a lack of evidence, the incident should be filed online. ED submitted the report online, provided R1 with a copy of the police report and case number, and informed DPOA that R1 had a hard copy. ED also filed reports with the Ombudsman and CDSS. ED stated that an in-service training was conducted with staff regarding residents’ rights, property protection, respecting personal space and belongings during care tasks, and elder abuse prevention. ED documented that R1 had waived declaring personal items on the inventory list at the time of admission. Theft and loss records were logged on LIC 9060. LPA reviewed R1’s LIC 602 Physician’s Report, Needs and Services Plan, and LIC 621 Resident Personal Property and Valuables (SPV) form. LPA observed that no personal property or valuable items were declared; the form was crossed out with “N/A” written and signed by R1. LPA attempted to visit R1's room but caregivers were in the middle of assisting R1 in the transfer to the bathroom for toileting and showering. No deficiencies were cited during today's visit. An exit interview was conducted with the Executive Director. A copy of this report was left with the Executive Director, Li Li, whose signature on this form confirms receipt of the report.the state’s words, verbatim · CDSS document, Jul 31, 2025

Type of visit: Case Management - Incident

On 07/21/2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident visit regarding an incident that occurred on 07/02/2025 between Resident #1(R1) and Resident #2 (R2), when R1 placed their hand on R2’s left chest. Upon arrival, LPA met with the Executive Director (ED), Li Li. The LPA disclosed the purpose of the visit. The Executive Director (ED) stated that the incident occurred around 12:30 PM in the Memory Care unit. After lunch, team members were focused on assisting residents with toileting and preparing them for their naps. Under the supervision of a full-time activity assistant, only a few residents remained in the activity room. When the caregiver (S1) entered the activity room, they observed that R1 was placing their hand on R2’s chest, inside R2’s clothing, but not making direct skin-to-skin contact. ED stated that after a few seconds, R1 removed their hand on their own. S1 then redirected R1 away from R2 and reported the incident to their supervisor. The charge nurse conducted a physical assessment of R2 and did not observe any scratches, red marks, or injuries. The following day, the incident was reported to the ED, as the ED had been off duty at the time of the incident. ED contacted the Palo Alto Police Department (PD), which took the report over the phone and decided not to respond in person, as there were no physical injuries involved. ED was provided with a police case number. ED further stated that they consulted with the Ombudsman, who indicated that there was no need to file an SOC 341 since there was no physical injury and the contact was indirect. ED notified both R1’s and R2’s physicians. Subsequently, the facility received a change in medication orders for R1 to address anxiety, and R1’s service plan was updated accordingly. Continued on LIC809-C ED stated that R1 was being closely monitored and that an intervention plan was being developed with staff to address how to manage similar incidents in the future. R1 was placed away from female residents during group activities. ED stated that they held a meeting with R1’s responsible persons to discuss the intervention plan and advised them that if R1’s behavior persisted, the facility might no longer be an appropriate setting for R1. ED also stated that they communicated with R2’s family regarding measures in place to keep R2 safe under close supervision and to ensure that R1 would not be seated in close proximity to R2. ED stated that R2 did not recall the incident or whether R1 had touched them inappropriately, and R2 remained at their baseline. R1 also did not recall the incident. ED further stated that staff training was conducted to help team members recognize and appropriately handle sensitive situations. No deficiencies were cited during today's visit. An exit interview was conducted with the Executive Director. A copy of this report was provided to the Executive Director, Li Li, whose signature on this form confirms receipt of the report.the state’s words, verbatim · CDSS document, Jul 21, 2025

Type of visit: Case Management - Incident

On May 28, 2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident inspection visit regarding a reported staff-to-resident physical abuse incident that occurred on 05/17/2025. The facility also reported SOC 341 for the same physical abuse incident. Upon arrival, the LPA was greeted by the Executive Director (ED), Li Li. The LPA disclosed the purpose of the visit. LPA interviewed ED and Resident R1. ED stated that on 05/17/2025, at 8:00 AM, Caregivers S1 and S2 were assisting a R1 in R1’s room during the AM shift. R1 was combative and agitated. R1 was hitting caregiver S1 on the arms, spitting on S1's face, and kicking S1 with their legs. S1 inappropriately slapped R1’s arm and tapped R1’s mouth using threatening language. S2 reported the incident to S4. Charge Nurse S3 assessed R1 and conducted a full body exam, finding no areas of redness, or discoloration, and no painful or tender areas. No injuries were noted. S1 was suspended and removed from the community. The incident was reported to S4, who was the manager on duty. Upon reviewing the situation, S4 immediately suspended S1 and escorted S1 off the community. S4 contacted the R1’s responsible party (RP) to inform them of the incident. R1’s Primary Care Physician (PCP) was notified of the incident on 05/20/2025. ED stated S1 was officially terminated yesterday, 05/27/2025. R1 have been on alert charting. R1 is fine, calm at baseline and was on frequently safety checks. ED further stated that Palo Alto PD was called on 05/22/2025, but no police has showed up, but there was a phone interview and R1’s and S1’s personal information was taken. Continued on LIC809-C RP was called on 05/17/2025 and RP had no concerns. ED followed up with RP over the phone again on 05/27/2025 to give update on R1. ED stated they will continue with elder abuse, resident’s rights, and policies of workplace violence prevention for California training for facility staff members. LPA conducted a wellness check on R1 by visiting their room. R1 was observed to be watching TV, closing his eyes often, and answered LPA questions by verbally responding and nodding. R1 stated he had no pain and doesn’t remember anyone tapping his mouth or slapping his arms or spitting on their face. R1 further stated no one used foul or threatening language with them. No deficiencies were cited during today's visit. An exit interview was conducted with the Executive Director. A copy of this report was left with the Executive Director, Li Li, whose signature on this form confirms receipt of the report.the state’s words, verbatim · CDSS document, May 28, 2025

Type of visit: Required - 1 Year

On May 21, 2025, at 9:00 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. LPA met with the Executive Director (ED), Li Li, and disclosed the purpose of the inspection. The facility consisted of two buildings with three floors each. First building was a combination of two assisted living units (elite care and assisted living), and two memory care units (meadow wing and focused care). The second building was for independent living. The ED informed the LPA that the facility had 179 residents in care at the time, including 93 in Assisted Living, 38 in memory care, and 48 in Independent Living. At 9:45 AM, LPA initiated a walk-through of the facility, accompanied by the ED. LPA inspected randomly selected ten (10) resident rooms in Assisted Living and Memory Care units. The rooms were found to be clean, well-lit, and equipped with the required furniture. Emergency pull cords were observed to be functioning in the resident rooms with an average response time of 5 minutes. LPA inspected the private bathrooms in these random rooms. The bathrooms contained soap, grab bars, towels, a trash can, and non-slip flooring. The hot water temperature at the sink faucets measured between 114.6°F and 116.8°F. “Oxygen in Use” signs were observed posted outside the residents’ room where oxygen was administered. LPA inspected the main kitchen and found it clean. The refrigerator, freezer, and pantry cabinets were checked, and there was a sufficient supply of fresh perishable food for two (2) days and nonperishable staples for seven (7) days. No expired food items were found. Open food items were wrapped and dated. The dining rooms in Assisted Living and Memory Care were inspected and were found to be clean, with all furniture in good repair. Continued on LIC809-C LPA inspected activity areas, library, media room, great room, fitness center, and other commons areas and observed residents actively engaged in recreational programs and activities. Activity calendar was observed posted at various locations throughout the facility. All common areas were free from obstructions, and hallways were well-lit. LPA inspected locked laundry stations on each floor and observed working washer and dryer units. Sharp objects, detergents, and chemicals were observed to be locked and inaccessible to persons in care. LPA inspected the fire extinguishers mounted on the hallway walls in Assisted Living and Memory Care and found them fully charged, with the last service tag dated 12/24/2024. The smoke detectors are tested semi-annually by a third-party vendor, Performance Systems Integrated with the last inspection completed on 03/11/2025. A staff member tested the carbon monoxide detector in the basement garage in LPA’s presence, and it was found to be functional. LPA toured the outside courtyard and patio areas and found passageways in good condition, free of obstructions, and without any blocking or tripping hazards. These areas had patio tables, chairs, and umbrellas for residents’ use. Delayed egress was observed on emergency exits and exterior exit doors were locked. No accessible bodies of water or hazards were observed. LPA reviewed six (6) staff personnel records and five (5) resident records. The LPA observed that 5 of 5 residents had the Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. LPA observed that 6 of 6 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 6 of 6 staff members were associated with the facility. LPA observed locked centrally stored medication carts in the Assisted Living and Memory Care units. Medications were organized separately for each resident. Narcotics were locked and the count was correct. All medication bottles and bubble packs were properly labeled. Centrally Stored Medication Records were reviewed and found to be complete. LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster (Fire and Earthquake) Drills were conducted monthly, with the most recent drill completed on 05/15/2025. The following updated forms are requested to be submitted to CCL by 05/28/2025: Continued on LIC809-C LIC 500: Personnel Report LIC 308: Designation of Facility Responsibility Certificate of Liability Insurance Administrator Certificate(s) No deficiencies were cited during today's visit. An exit interview was conducted with the Executive Director. A copy of this report was provided to the Executive Director, Li Li, whose signature on this form confirms receipt of the report.the state’s words, verbatim · CDSS document, May 21, 2025

Allegation investigated: 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

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 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. 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.the state’s words, verbatim · CDSS document, May 6, 2025 · control 26-AS-20220927080512

Allegation investigated: Staff did not provide adequate supervision resulting in a resident wandering into an unsafe area

On April 23, 2025, at 12:10 PM, Licensing Program Analyst (LPA) Kiran Jain arrived at the facility to deliver the findings of a Complaint Investigation. Upon arrival, the LPA was greeted by the Business Office Director (BOD), Diana Smith. The LPA disclosed the purpose of the visit. Regarding the allegation “Staff did not provide adequate supervision resulting in a resident wandering into an unsafe area”, the Reporting Party (RP) stated “the 2 elevators at this facility do NOT have an override key to prevent residents from entering dangerous locations--in this case, the locked garage where cars are parked and construction equipment is stored. the elevators are programmed to go to the basement if at any point that floor is selected Case in point: a resident there, has a room on the 2nd floor. Entered on the ground floor and pushed level 2. Resident is recovering from brain surgery and relearning how to walk; also has memory issues, uses a wheelchair. Continued on LIC9099-C Unsubstantiated The wheelchair was found in the basement garage and the resident was found on the entry level floor, one level above the garage. Apparently, resident had abandoned the wheelchair in that garage, found a door that opened to cement stairs and crawled up those stairs to the ground floor. Fortunately, suffered no harm, no broken bones. This building was built in the 1990s. I wondered if the elevator safety enforcement has been buy-passed by having the elevators grandfathered in. I would like an elevator inspection done on those 2 elevators and also include in the inspection, the door closing procedures involving speed and human touch prevention". LPA interviewed one (1) resident (R1) and six (6) staff members (ED, HWD, S1, S2, S3, and S4). R1 stated that they came downstairs on their own and likely used the front lobby elevators. When asked if they had recently taken the elevator to the basement parking garage, R1 responded, “Don’t know.” When asked whether they enjoyed going outside to the patio area, R1 replied, “I don’t like to go outside.” R1 did not recall whether they had undergone surgery recently. The Executive Director (ED) stated that there had been an incident in which R1 took the elevator to the garage, left their wheelchair there, and was later found in the Meadow Wing Memory Care Unit by a staff member who recognized that R1 did not belong in that unit. Staff member (S4) contacted R1’s family (FM) to inform them of the incident. The ED mentioned that R1 had undergone surgery prior to moving into the facility and did not have a diagnosis of dementia or mild cognitive impairment (MCI). According to the ED, R1 was capable of walking with a walker and by using hand railings and was also able to self-propel their wheelchair. R1 was described as vocal and able to express their needs clearly. The ED further stated that a technician visits the facility once per quarter to perform preventive elevator maintenance and testing, with additional service calls placed as needed between scheduled visits. The ED explained that construction equipment had been temporarily stored in the garage, surrounded by yellow caution tape, but it had been removed well before R1 accessed the garage on March 13. The ED stated that the garage area was considered very safe, no residents had previously accessed it by accident, and they could not recall any prior incidents occurring there. HWD stated that R1 was escorted by staff from the Memory Care Unit to the Assisted Living activities room, and from there, R1 was escorted to the dining room. S1 stated that their office was located near the Memory Care Unit, and they were notified by a staff member about a resident from the Assisted Living area being present in the Memory Care Unit. S1 observed R1 walking without the use of any assistive device. Continued on LIC9099-C S1 instructed S2 to conduct an assessment of R1 and directed other staff members to locate R1’s wheelchair. After the assessment, S1 directed that R1 be escorted to the activities room. S1 stated that R1’s wheelchair was found near the back elevators in the basement, which was the same elevator routinely used by R1’s family member when returning R1 to the facility. According to S1, this was part of their regular routine. S1 also stated that the garage was considered safe, and the front elevator door leading to the street was always locked and alarmed. The elevators were described as safe and regularly inspected. S1 added that construction materials had been stored in the garage during ongoing construction, but those materials had been removed prior to R1 accessing the garage on March 13. S2 stated that they assessed R1 in the Memory Care Unit to determine whether R1 had sustained any injuries, experienced pain, or had any skin tears. S2 did not observe any skin tears or discoloration on R1’s body. S2 then contacted the Assisted Living nurse and relayed information to S4, instructing them to notify R1’s Power of Attorney (FM) and physician. S2 stated that the elevators were safe and equipped with sensors that detect obstructions, such as a hand, and prevent the doors from closing completely. S2 also stated that the basement garage was safe, noting that the door leading to the street was alarmed and would trigger a notification if opened. S3 stated that elevator maintenance was conducted quarterly unless an issue arose that required a service call, and that the elevators had been functioning properly. A few elevator buttons had come off and were subsequently replaced. S3 mentioned that the facility underwent an annual inspection by the state; however, due to a backlog, the inspection company informed them that the letter from 2022 remained valid. This inspection letter was still posted inside the elevator. S3 explained that the elevators were equipped with a safety prevention mechanism: when the doors began to close, any interference would break a beam of light detected by a sensor, causing the doors to reopen. The doors would remain open for a designated period before attempting to close again. This feature was intended to ensure resident safety. S3 considered the garage to be safe for residents and stated that the construction materials previously stored there had been removed between January and February 2025, after being present for approximately two to three months. S4 stated that S2 had sent them an incident report regarding R1 and instructed them to notify R1’s doctor and family (FM) about the incident in which R1 was found in the Memory Care Unit. S4 explained that S2 had conducted a head-to-toe assessment of R1 and found that R1 was neither distressed nor disoriented. S4 stated that care staff conducted hourly checks on R1, and R1 had not exhibited any exit-seeking behavior; otherwise, it may have become a recurring issue. Continued on LIC9099-C S4 expressed that they believed the garage was safe, noting that alarms were installed next to the door leading outside. If the door was opened, the alarm would be triggered and send a notification upstairs. S4 also mentioned that they did not have any safety concerns regarding the elevators. LPA reviewed R1’s Admission Agreement and noted that R1 moved into the facility around July 26, 2024. LPA reviewed R1’s LIC 602 Physician’s Assessment, dated July 17, 2024. The assessment indicated that R1 was not diagnosed with dementia or mild cognitive impairment (MCI). R1’s primary diagnosis was listed as cerebral embolism. The assessment described R1’s mental condition as follows: R1 was not confused or disoriented, did not exhibit wandering behavior, was able to follow instructions, and could communicate their needs. R1 was classified as nonambulatory due to their physical condition and was noted to be recovering from surgery. LPA reviewed R1’s progress notes dated March 13, 2025. According to the notes, staff observed R1 walking in the Meadow Wing Memory Care Unit. Staff escorted R1 back to the Assisted Living. R1 was assessed and found to have no visible injuries. R1 denied experiencing any pain or discomfort and was observed to be at their cognitive and physical baseline. R1’s wheelchair was later located in the basement garage. LPA reviewed the facility’s Internal Incident Report Review dated March 13, 2025. According to the report, R1 was found in the Meadow Wing Memory Care Unit and was escorted to the Assisted Living activity room. R1 was observed walking without a wheelchair, which was later located in the basement garage. R1 was assessed and found to have no visible injuries and denied experiencing any pain or discomfort. R1’s primary care physician (PCP) and family member (FM) were notified. According to the follow-up comments in the report, the family member stated that that R1 wasn’t wandering and was probably looking for FM to take R1 home. LPA reviewed the Elevator maintenance report and invoices. According to the invoices, the facility is on quarterly maintenance service. Maintenance report showed general maintenance service and other as needed service records, with the last general maintenance procedure for the hydro-hoist-way/car performed on January 08, 2025. During the facility visit on March 20, 2025, LPA took the front elevators from the first floor to the second floor and then down to the basement parking garage. Continued on LIC9099-C Upon exiting the front elevators in the basement, LPA observed two (2) doors. One door, which led to the street, was alarmed. When opened, the alarm would be triggered, and the front desk would be notified. This door had a sign posted that read, “Stop, Alarm will sound.” The second door led into the secured garage area. LPA inspected the garage and observed that no construction materials were stored in the area. LPA then walked toward the second elevator located in the garage and took it up to the first floor. LPA tested the door sensors on both elevators by placing a hand between the doors as they were closing. The door sensors detected the obstruction and prevented the doors from closing. No issues were observed with the door-closing mechanisms on either elevator. Both elevators had notices posted indicating that permit renewals were in process. The garage had only one exit to the public street, which was through a sliding iron gate. This gate could be opened from the outside using a code, clicker, or by the front desk, and it could be opened from the inside when it detected an object. LPA went to R1’s room on the second floor accompanied by the ED. R1 was not in the room. LPA saw R1 in the first-floor common area sitting on their wheelchair. Based on observations, interviews conducted, and records reviewed, the department has determined that the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegation(s) are UNSUBSTANTIATED. No deficiencies were cited under the California Code of Regulations, Title 22. An exit interview was conducted with the Business Office Director. A copy of this report was discussed and provided to the Business Office Director, Diana Smith, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Apr 23, 2025 · control 26-AS-20250314135711

Type of visit: Case Management - Incident

On March 27, 2025, at 8:55 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident visit regarding an incident that occurred on 03/19/2025 when the resident (R1) was given a PRN as needed medication by mistake. Upon arrival, the LPA was greeted by the Health and Wellness Director (HWD), Patricia Oliver and Business Office Director (BOD), Diana Smith. The LPA disclosed the purpose of the visit. LPA interviewed one (1) resident (R1) and four (4) staff members: Executive Director (ED), Health and Wellness Director (HWD), Medication Technician (S1) and LVN Community Nurse (S2). HWD stated that on 03/19/2025, R1 was given ‘Labetalol,’ a medication that was ordered as needed. R1 knew their medications well and told the Med Tech that they were not supposed to have the medication unless there was a specific need for it and R1 said they should not have received this medication. HWD stated that S1 did not read or recognize the medication order on the QMAR as an as-needed order, and R1 was concerned about having received the wrong medication. HWD stated that R1 had been diagnosed with Parkinson’s and was receiving care in the elite care unit following their return from the hospital for a UTI. R1 had been alert and oriented. HWD mentioned that S1 had reached out to S2, who then performed a bedside assessment of R1. S2 called and faxed R1’s PCP regarding the medication error and received instructions from the PCP on the care plan in response to the error. HWD stated that the facility held a care conference call with R1’s family to explain how the medication error occurred and what actions the facility was taking to prevent similar errors in the future. Continued on LIC-809C ED stated that S1 had administered ‘Labetalol,’ a PRN medication, thinking it was a routine medication. The medication was supposed to be given only as needed, after checking the blood pressure and confirming it met certain parameters. R1 took the medication and asked S1 which medications had been given. S1 and R1 both realized at the same time that the wrong medication had been administered. R1 remained stable and experienced with no side effects. S2 reached out to R1’s PCP regarding the medication error. ED stated that they had conducted a Zoom meeting with R1’s family on the same day. ED stated that S1 had been working at the facility for a long time and was a very good med tech who cared deeply for the residents. S1 stated that on 03/19/2025, they had given R1 their morning medications at 8:30 AM. The ‘Labetalol’ PRN medication had appeared as a routine medication in the QMAR. The medication was supposed to be administered only if R1’s blood pressure exceeded the specified parameter. S1 stated that R1’s blood pressure had been below that parameter, but they had still administered the medication. They acknowledged it was their error. After checking the QMAR, they realized the parameter did not support giving the medication. S1 stated that R1 had asked for the names of the medications given to them but had not said anything about why the ‘Labetalol’ had been administered. S2 stated that the ‘Labetalol’ medication had been set as a routine medication in the QMAR but included a parameter indicating it should be given only if the blood pressure exceeded a certain threshold. R1 had moved to the elite care unit on 03/13/2025 or 03/14/2025. S2 stated that S1 had called them, and S2 had informed R1 that the ‘Labetalol’ had been administered in error. S2 stated that R1 appeared anxious but not visibly upset. S2 performed a blood pressure reading and asked R1 how they were feeling. S2 called R1’s PCP, reported the medication error, and coordinated with the PCP regarding R1’s care plan following the error. R1 stated that they were aware of the medication error involving ‘Labetalol’ and knew which medications they were supposed to be taking, as they always asked. R1 stated that the facility had categorized ‘Labetalol’ as a routine medication. R1 also stated that some individuals at the facility did not know the purpose behind certain medications. These individuals were new and only knew the quantity of medications to administer. R1 stated that their blood pressure was highly variable and that they had other conditions that put them at high risk for stroke, making such medication errors potentially life-threatening. R1 stated that they could not remember how they felt on the specific day the ‘Labetalol’ was given in error; they generally felt tired and lethargic but had no recollection of that particular day. Continued on LIC809-C R1 stated that similar errors had occurred in the past at the Commons. Staff did not understand the doctor’s order and used their own interpretation instead of contacting the doctor for clarification, which was not how the doctor intended the medication to be used. R1 stated that they felt additional staff training, increased supervision, more managerial oversight, and frequent evaluations of medication administration practices at Commons could help prevent such errors. LPA reviewed R1’s hospital discharge notice, dated 03/13/2025, which indicated to administer one ‘Labetalol’ as needed for SBP >170 or DBP >105. LPA reviewed R1’s vital signs record. The blood pressure reading taken at 8:43 AM on 03/19/2025 showed reading written as 146/90. LPA reviewed R1's Medication Administration Record (MAR). The 'Labetalol' 100 MG medication was listed as needed for SBP>170, DBP>105. LPA reviewed R1's Centrally Stored Medication Records, which showed Labetalol' medication listed with instructions "Take 1/2 tablet (50 MG) as needed SBP>170, DBP>105. LPA reviewed the faxed note sent to R1’s doctor indicating that a medication error had occurred. R1 had been given ‘Labetalol’ 50 mg despite a blood pressure reading of 146/90. A deficiency was cited based on LPA observations, record reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted, and Plans of Correction were reviewed and developed with the Business Office Director. A copy of this report and appeal rights were discussed and provided to the Business Office Director, Diana Smith, whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Mar 27, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Mar 28, 2025

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated…facility staff designated… (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on observations, interviews, and records review, the facility staff did not ensure R1 was given the prescribed PRN medication according to the physician's directions, which posed an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: The Business Office Director will develop a plan to ensure correct medications ordered by physician are always given to the residents. The Business Office Director will provide a copy of the plan to CCLD by 03/28/2025.

Type of visit: Case Management - Incident

On March 11, 2025, at 9:00 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident inspection visit regarding an incident when the resident (R1) presented with a sudden change of condition and the nurse assessed and observed that the resident had removed his supra pubic catheter. Upon arrival, the LPA was greeted by the Executive Director (ED), Li Li. The LPA disclosed the purpose of the visit. The ED informed the LPA that the total facility census was 183. Based on the review of the facility file records, the facility did not have an exception granted in place for R1’s suprapubic catheter, a restricted health condition. LPA and ED had a phone conversation with Mariam Perez, Vice President of Clinical Services at Wellquest Living (VP). VP stated they had a phone call with CDSS on March 7, 2025 and were told there was no need to file an exception request for catheter. ED stated they had the requested documents ready to submit for an catheter exception request, if there was a need to be. No deficiencies were cited during today's visit. An exit interview was conducted with the Executive Director. A copy of this report was left with the Executive Director, Li Li, whose signature on this form confirms receipt of the report.the state’s words, verbatim · CDSS document, Mar 11, 2025

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

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 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. Page 2 of 3. 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. Page 3 of 3. END REPORTthe state’s words, verbatim · CDSS document, Mar 7, 2025 · control 26-AS-20220721135927

Type of visit: Case Management - Incident

On March 04, 2025, at 9:00 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident inspection visit regarding a reported Theft and Loss incident that occurred on 02/24/2025. The facility also reported a SOC 341 for the same Theft and Loss incident. Upon arrival, the LPA was greeted by the Executive Director (ED), Li Li. The LPA disclosed the purpose of the visit. The ED informed the LPA that the total facility census was 186. According to the ED, on 02/15/25, a hospice resident (R1) passed away at the facility in the presence of hospice nurse and facility staff member. No R1's family members were present. On 02/23/2025, R1’s family member (FM1), arrived at the facility to pack R1’s belongings. FM1 came to the front desk and requested to unlock R1’s room. Floor shift leader unlocked the room. ED stated that about 30 minutes later, FM1 raised concerns to ED that some of the items were missing from R1's room - watch, wallet and Apple iPad. ED suggested FM1 to thoroughly check R1’s personal items and meet with ED the next day, when FM1 had a check list of missing items. FM1 agreed to meet ED the next day. On 02/24/2025, FM1 met with ED and reported following missing items, listed with their Dollar ($) value: 1) wallet worth $25.00, 2) new watch worth $500.00, 3) Apple iPad tablet worth $1,00.00, 4) Camera equipment worth $10,000.00, 5) music box worth $750.00, and 6) Faberge Pinecone Egg worth 2,000.00. The total value of missing items was $14,275.00. ED stated that R1 moved into the facility on 11/27/2024, initially to room #108 and then to room #113. Family hired movers during both the moves. The facility checked the room #108 to make sure nothing was left behind in the room, after R1 moved to room #113. On 2/24/2025, ED and FM1 thoroughly checked R1’s apartment for missing items. ED called Palo Alto Police Department (PD). PD’s officer arrived and searched R1’s apartment for the missing items and obtained the details of the missing items. A PD case was opened. Continued on LIC809-C ED stated that during the last few days of the resident's passing there were quite a few visitors. Three (3) hospice staff visited R1 during the day of their passing. On 02/17/2025, a medical equipment company hired by the Hospice came to the facility to dissemble the hospital bed and pick up the bed and other equipment like portable oxygen tank. ED stated, at this moment, none of the visitors can recollect seeing these missing items. Facility was currently waiting to hear back from the police department. LPA reviewed R1’s admissions agreement. FM1 was designated to remove R1’s personal property upon death. FM2 was R1’s POA, whose signed the admission agreement. On, 11/25/2024, FM2 signed and dated resident’s personal property and valuables form, but never declared the items on the form. LPA reviewed facility’s loss and theft policy, and in service training record for theft and loss policy. LPA reviewed the visitor’s sign in sheet record for R1. LPA reviewed LIC 9060 Resident Theft and Loss Record listing the items that were reported missing by FM1. No deficiencies were cited during today's visit. An exit interview was conducted with the Executive Director. A copy of this report was left with the Executive Director, Li Li, whose signature on this form confirms receipt of the report.the state’s words, verbatim · CDSS document, Mar 4, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Executive Director Li Li. The purpose of the visit was to obtain copies of resident records. During visit, LPA Marrufo obtained copies of resident records. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Executive Director Li Li and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 7, 2025

Allegation investigated: Staff are holding resident against their will

On January 15, 2025, at 9:00 AM, Licensing Program Analyst (LPA) Kiran Jain arrived at the facility to conduct a Complaint Investigation visit. Upon arrival, the LPA was greeted by the Executive Director (ED), Li Li. The LPA disclosed the purpose of the inspection. The ED informed the LPA that there were (184) residents in care. Regarding the allegation “Staff are holding resident against their will”, the Reporting Party (RP) stated “Resident (R2) is being held at this facility against R2’s will. R2’s care nurse (GCM), placed R2 in this facility to allegedly hide abuse. R2 has tried to voice their opinion about wanting to leave the facility, but R2 is not being properly heard and/or investigated. R2’s PCP is also not aware and was not consulted on R2 being moved into this facility”. Continued on 9099-C Unfounded On 12/19/2024, LPA attempted to interview Resident (R2) at the facility, but R2 was sleeping at that time. LPA interviewed Resident (R1), who stated that they could come and go from the facility whenever they wanted and were free to move around inside the facility as well. LPA interviewed a staff member (S1), who stated that they had not heard any residents express a desire to leave the facility and confirmed that no resident was being held at the facility against their will. On 12/24/2024, LPA reviewed the facility’s Staff Roster and noted that the care nurse's (GCM) name was not listed on the staff roster. LPA reviewed the facility’s Resident Roster and observed that R2’s name and room number were listed on the roster. LPA reviewed R2’s LIC 601 Identification and Emergency Information form and noticed that GCM’s name was listed under the placement agency and as an emergency contact (friend). The LIC 601 form had been completed and signed by GCM on 09/04/2024, with GCM's title written as "Geriatric Care Manager" on the form. From R2’s LIC 601 form review, LPA obtained the contact information for R2’s Family Member (FM1), Persons Responsible for Financial Affairs (FRP1 and FRP2), and Primary Care Physician (PCP2). On 12/24/2024, LPA reviewed R2’s LIC 602 Physician’s Report, dated 09/19/2024, which stated R2’s primary diagnosis as Dementia with behavioral disturbances. LPA reviewed R2’s LIC 603 Preplacement Appraisal Information form, which had been completed and signed by GCM on 09/03/2024. On 01/03/2025, LPA interviewed R2’s Fiduciary/Trustee/Financial Responsible Persons (FRP1 and FRP2). FRP1 and FRP2 stated they had been brought in by R2’s attorneys as co-trustees and had paid R2’s bills while ensuring R2’s needs were met. FRP1 and FRP2 stated that R2’s Family Member (FM1) had been the decision-maker and that the care manager (GCM) had advised FM1 regarding R2’s care. FRP1 and FRP2 stated that the decision to move R2 to the memory care facility had been made between FM1 and GCM. On 01/03/2025, LPA interviewed Family Member (FM1), who stated that R2 had been moved to the facility around August or September 2024. FM1 stated that FRP1 and FRP2 had mentioned to them that R2 would not have enough money left for at-home care and that GCM, who had been hired by FRP1 and FRP2, had proposed that R2 be moved to a memory care facility due to Dementia. FM1 agreed, as this ensured R2’s money would not run out and R2 would receive proper care at the facility. FM1 stated they had tried and done their best in R2’s interest. FM1 stated that R2’s previous tenant (FTE), who had also been listed in R2’s will and had been R2’s POA, then had declined to continue as R2’s POA and FTE hired FRP1 and FRP2 to manage R2’s finances. FM1 stated that R2’s dementia had been slowly progressing since 2015. Continued on 9099-C On 01/03/2025, LPA interviewed R2’s current Primary Care Physician’s office (PCP1). PCP1 stated they were a mobile care service based out of Southern California and provided mobile concierge services throughout California. PCP1 stated that R2’s physician was based in the Sacramento area and that R2’s LIC 602 had been filled out on 09/19/2024 by a nurse practitioner. On 01/03/2025, LPA interviewed R2’s former Primary Care Physician’s office (PCP2). PCP2 stated that R2 was no longer a patient at their clinic and that their office had been notified by R2 that they no longer needed a Primary Care Physician from their office. On 01/07/2025, LPA interviewed R2’s former tenant (FTE), who stated that they had been a good friend of R2, had worked as R2’s bookkeeper, and had assisted with R2’s finances. FTE mentioned that, before 2015, they had lived in R2’s house as a tenant and had been added to R2’s will around April 2019, prior to R2 being diagnosed with dementia. FTE stated they had sold R2’s properties at the end of 2021 or early 2022 to help R2 financially. FTE further stated that R2 had been diagnosed with dementia in January 2022 and that R2’s physician (PCP2) had provided a letter confirming the diagnosis at that time. In 2022, FTE stated they had hired fiduciaries (FRP1 and FRP2) to manage R2’s affairs. After that, FTE lost contact with R2 and believed R2 continued to live in the same house. On 01/08/2025, LPA interviewed R2’s Geriatric Care Manager (GCM). GCM stated they work for a private company and were taking care of R2, coordinating with R2’s POA (FM1) and Fiduciary (FRP1 and FRP2). GCM stated R2 had advanced dementia, refused essential care services at home, and would wander at streets. POA made the decision to move R2 to memory care. GCM stated FM1 hired the fiduciary (FRP1 and FRP2), and GCM were hired by both FM1 and the fiduciary about 1 year ago. GCM stated they changed R2’s primary care physician to PCP1 as R2’s former PCP (PCP2) was out of the county when R2 needed to move to the facility. GCM stated R2 was diagnosed with dementia back in 2011, but are not sure, since they don’t have R2’s chart in front of them, and R2’s physician had written a letter indicating R2 didn’t have the mental capacity to make decisions. GCM stated that based on their guess this letter was written around 2011 or a bit later in 2018. FM1 had this letter and POA was invoked after that. GCM stated that R2 was moved to the Palo Alto Commons facility in December 2024, and initially, R2 sometimes packed their stuff to leave the facility and walked towards the door, but never walked out the door. GCM stated that R2 was now calm and happy at the facility. Continued on 9099-C On 01/08/2025, LPA Jain interviewed R2’s attorney (ATT), who stated that R2 was no longer their client and that their professional relationship had ended about a year and a half ago due to concerns about R2’s capacity. ATT stated that they had been unable to transfer R2’s files to R2’s fiduciaries (FRP1 and FRP2) because the fiduciaries did not have proper authorization from R2. On 01/15/2025, LPA interviewed the facility’s Executive Director (ED), who stated that R2 had not been held at the facility against their will. Initially, R2 had been unhappy upon entering the facility, but R2 was happy now, hugged caregivers, and enjoyed the food. R2 had made friends, was more relaxed, and had not been agitated. R2’s POA had initiated the move to the facility due to concerns about R2's safety at home, including wandering issues and dementia, as well as the challenges caregivers faced in meeting R2’s care needs at home. The ED explained that the facility had used a mobile concierge service to assess R2 and complete licensing forms, as R2’s needs were urgent for the placement. The ED also stated that they were unaware that R2’s primary care provider (PCP) had not been informed about R2’s move to the facility. Furthermore, the ED confirmed that R2 was free to move around the facility and had never been restrained by any caregiver. On 01/15/2025, LPA interviewed Resident (R2), who stated that they liked the facility but did not want to live there permanently, as they were temporarily staying at the facility for one week. R2 mentioned that they liked their home but could not remember how long they had lived there. R2 also stated that they had recently met the facility's caregivers and liked them. Based on records reviewed and interviews conducted, it was determined that the care nurse (GCM) was not an employee of the Palo Alto Commons facility. GCM was identified as a Geriatric Care Manager employed by a private company. The department has determined that the allegation is false, could not have happened, and/or is without a reasonable basis. Therefore, the allegation is UNFOUNDED. No deficiencies were cited under the California Code of Regulations, Title 22. An exit interview was conducted. A copy of this report was discussed and left with the Executive Director, Li Li, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Jan 15, 2025 · control 26-AS-20241218103905

Allegation investigated: Staff do not provide comfortable accommodations for the residents Resident is not afforded privacy while in care Resident's room is in disrepair Staff do not have planned activities for the residents

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Administrator (ADM) Li Li. On 07/18/2023, the Department received a complaint with the above allegations. On 07/26/2023, LPA Marrufo conducted an initial complaint investigation visit. R1’s Admission Agreement was signed by R1’s Responsible Party (RP) on 02/20/2020. Page 23 of R1’s Admission Agreement states, “M. Substitution of Apartment We reserve the right to substitute your Apartment with another apartment in our sole discretion. We will make reasonable accommodations with respect to your preferences concerning apartment and roommate choices. We will provide you with thirty (30) days’ written notice before substituting your Apartment, unless you agree to the request for change, it is required to fill a vacant bed, or it is necessary due to an emergency. You agree to such apartment substitution and agree to pay the Monthly Fee applicable to the new apartment.” See LIC9099-C for more information. Page 1 of 5. Unsubstantiated OT1 stated to be privately paid for by R1’s family and is not a facility staff. OT1 stated that facility staff have left R1 in bed as late as 2 PM. OT1 stated R1 likes to get out of bed by 11 AM or by lunchtime. OT1 stated to not know how many times staff left R1 in bed, but stated it was an ongoing issue for about a month. OT1 stated staff would tell OT1 that they left R1 in bed because R1 had not had a bowel movement yet and it would be easier for R1 if R1 was left in bed. However, OT1 stated R1 would tell OT1 that the staff would just leave R1 in bed. Based on interviews, there is preponderance of evidence to prove the alleged violations did occur. Therefore, the allegation is substantiated. See 9099-D for deficiencies cited per the California Code of Regulations, Title 22. This report was reviewed with Administrator Li Li and a copy of this report and appeal rights were provided. Page 2 of 2. END REPORT LPA obtained copies of letters addressed to facility residents and family members on 12/15/2022 and 05/09/2023, as well as an Outlook calendar appointment with a link to a Zoom meeting that occurred on 06/02/2023. The letter dated 12/15/2022 states that there will be a renovation project that will include the facility entryway, courtyard, reception area, administrative area, and aspects of the dinning room. The letter states WellQuest leadership would be on campus on 12/20 at 2:30 PM to meet with residents. The letter from 05/09/2023 states that renovations at the community would begin on 06/05/2023 and there would be a community meeting to ask questions about the renovation project on 05/24/2023. The letter requested an RSVP by 05/20/2023. The Outlook calendar appointment is for a Zoom meeting that occurred on 06/02/2023 and had the subject “Palo Alto Commons Renovation: Community Meeting.” During interview on 07/26/2023, ADM stated that ADM gave RP a tour of the proposed new apartment for R1 since RP was complaining that there was too much construction noise around R1’s current apartment. ADM stated to have told RP that the new apartment does not have a rolling shower like R1’s current apartment. ADM stated to have told RP that R1 would be more comfortable in R1’s current apartment. ADM stated to have told RP that there is a shower room on the second floor for residents whose apartments do not have wheelchair accessible showers. LPA Marrufo obtained copies of emails between Administrator (ADM) Li Li and RP that are dated from 06/12/2023 to 07/17/2023. On 06/12/2023, ADM sent an email to RP confirming a meeting and the subject of the email is “Re: Moving [R1] to new room.” In an email on 06/14/2023, ADM told RP that another apartment will be on hold for R1 to move into should RP approve the move. On 06/19/2023, RP responded to ADM’s email and stated that RP wants to move R1 to the new apartment. On 07/10/2023, RP emailed ADM stating that R1’s new apartment has no privacy, has a bathroom and kitchen that is not accessible by wheelchair, has a bedroom with a broken door, and has no privacy as it faces a walkway used frequently used by employees. RP requested a reduction of $2,500 to R1’s monthly bill to compensate for RP’s complaints about R1’s new apartment. Page 2 of 5. On 07/14/2023, ADM responded to RP’s previous email and apologized for the broken bedroom door. ADM stated the maintenance team would repair the door. ADM stated to have discussed the inconvenience of the shower room in the new apartment during the tour, but RP had wanted to move R1 away from the ongoing construction. ADM offered R1 a monthly rental credit of $1,000 until the renovation project was completed and R1 could return to R1’s original apartment. ADM stated staff members are requested not to access the side door to ensure R1’s privacy unless there is an emergency. On 07/17/2023 at 11:35 AM, RP responded to ADM’s previous email and did not agree to accept the $1,000 monthly credit. RP stated, “Please grant the reduction of $2,500 and we will consider the matter closed.” On 07/17/2023 at 4:18 PM, ADM responded to RP’s previous email respectfully disagreeing with RP’s proposal of a $2,500 monthly credit and again proposed a $1,000 monthly credit. On 07/17/2023 at 5:12 PM, RP stated to have been disappointed in ADM’s response. On 07/17/2023 at 5:18 PM, ADM stated that ADM’s supervisor has approved of RP’s request and R1 will receive monthly credits of $2,500 from 07/01/2023. On 07/17/2023 at 5:32 PM, RP accepted the $2,500 monthly credit. On 07/14/2023, ADM sent an email to RP and stated staff members are requested not to access the side door to ensure R1’s privacy unless there is an emergency. During interview on 07/26/2023, R1 stated to have privacy in the new apartment. R1 stated there is an exit door in the bedroom and R1 has been cautioned not to open it. R1 stated a staff comes each night to ensure the door is closed. R1 stated R1 is able to close the blinds if R1 wants privacy. Page 3 of 5. During visit on 07/14/2023, LPA Marrufo observed R1’s new apartment. LPA observed a sliding glass door in R1’s bedroom that faced an exterior walkway. The door had a metal pole attached to it that prevented the door from sliding open. LPA observed two sets of window curtains installed over the sliding glass door. On 06/14/2023, ADM sent RP an email and proposed a move-in date of 06/22/2023 for R1 to move into the new apartment. On 07/10/2023, RP sent ADM an email stating that the door facing the exterior of the building in R1’s bedroom was broken. On 07/14/2023, ADM sent an email to RP apologizing for the inconveniences caused by the broken door in the bedroom. ADM stated a work order has been sent to the maintenance team to repair the bedroom door. During visit on 11/14/2024, LPA Marrufo interviewed staff S1, Director of Environmental Services. S1 stated that RP stated that R1’s sliding glass door was not locking. S1 stated to have observed the sliding glass door and the door had a pole installed that latched in order to lock the door. S1 stated that the pole had to be flipped upwards to be latched and locked and most people thought that the pole would need to be latched downwards to lock. S1 stated there was a “flipper” at the bottom of the door that allowed the door to be open about 3-4 inches for ventilation purposes. S1 stated the “flipper” was installed on the sliding glass door because it is an exterior door and due to safety concerns, the door was not meant to be opened all the way. S1 stated to have not observed any damage to the door. S1 stated there is no record of a work order put in for the door on either June or July of 2023. S1 stated to have taken a video of the door and showed in the video how the door was locked with the latch. S1 stated to have shown the video to ADM on S1’s mobile phone. S1 stated to have not discussed the door or shown the video to RP or R1. S1 stated that usually if there are any problems with exterior doors, the exterior doors are either repaired or replaced right away, since the exterior of the facility is a safety concern. S1 found the video on S1’s mobile phone and showed the video to LPA Marrufo. S1 showed LPA the video of S1 flipping up the latch, sliding open the door, sliding the door closed again, locking the door, and lowering the pole. S1 also showed the flipper at the bottom railing that prevents the sliding glass door from fully opening. S1 stated the video is dated 07/17/2023. Page 4 of 5. During visit on 11/14/2024, LPA Marrufo toured the apartment into which R1 had been transferred. LPA observed that the bedroom now had a wall with a window instead of a sliding glass door. S1 stated the sliding glass door had been changed to a window and wall as part of the facility renovation process. During visit on 11/14/2024, ADM stated during interview to have discussed the proper way to lock the sliding glass door with RP. During interview on 07/26/2023, R1 stated that staff provide activities such as bingo, book group, and rest and relaxation. R1 stated many residents attend the activities. LPA Marrufo obtained the activity calendars for the months of June and July 2023. The calendars indicated that there were 5-6 activities scheduled each day. LPA Marrufo obtained copies of the Book Club Sign-Up forms for the months of June and July 2023. R1’s name is listed on both sign-up forms. During visit on 07/26/2023, LPA Marrufo toured the facility. During the visit, the facility was still undergoing renovation. LPA observed 8 residents in a facility meeting office room that had been repurposed as an activity room. The residents were watching a video on a television that had been installed in the office room. LPA photographed an activity schedule posting for 07/27/2023 that posted 6 different activities scheduled. The activities were being held in the Hobby Room, Dinning Room, and Lobby. 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. Page 5 of 5. END REPORT.the state’s words, verbatim · CDSS document, Nov 14, 2024 · control 26-AS-20230718091433

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Nov 15, 2024

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by: resident R1 was left in bed multiple times past 1 PM, which poses an immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: Licensee agrees to submit a plan of correction to ensure that staff are sufficient in numbers and competent to provide the services necessary to meet resident needs, including assisting residents in transferring out of bed. Licensee agrees to conduct in-service training with staff and submit staff training records to CCL once training is completed, including training topics, names of staff trained, training dates, and names and qualifications of trainer(s).

Type of visit: Case Management - Incident

On 11/12/2024, Licensing Program Analyst (LPA) Kiran Jain conducted an unannounced case management visit to follow up regarding an incident that occurred on 11/04/2024 where resident (R1) eloped from the facility after attending a birthday concert at the facility’s great room. LPA Jain met with Executive Director, Li Li and explained the purpose of the visit. On 11/04/2024, R1 eloped from the facility around 3:35 PM during a birthday concert unsupervised. R1 was observed to be eating cake in the great room around 3:30 PM. R1 was stopped by the owner of a martial arts studio down the street from the facility and the studio owner called 911. EMT called the facility to let them know on R1’s condition and location. Based on the interview conducted with Executive Director (ED), ED stated R1 was at a birthday party celebration in the great room from 2:30 PM to 3:30 PM and there were about 20 residents, and 2 activities assistant staff members present during the birthday concert event. After the event, R1 got up and walked back to their room on their own. R1 then came back out to the living room from their room and wandered out by walking out of the front door of the facility without notifying anyone. No one witnessed that. R1 walked into a local shop and said that they are local and are very tired. Shop owner was surprised to see an elderly in distress breathing heavily and called 911. EMT called facility to notify about R1’s location. Facility staff members went down the street to pick up R1. When staff arrived, R1 was sitting on a bench and answering questions with EMTs. Staff members recommended to send R1 to the Hospital for further evaluation and observations. ED stated R1 is high functioning, walks with a walker, never showed any wander behaviors prior to the incident. ED stated that R1 is part of Elite care in Assisted Living, where there are 7 staff members to take care of 24 residents. Based on the review of R1’s Physician’s Report (LIC 602) dated 06/08/2023, R1 has a primary diagnosis of Dementia, is non-ambulatory due to mental condition and deemed not able to leave the facility unassisted. The facility staff failed to ensure that R1 doesn’t leave the facility unassisted, which posed an immediate health, safety or personal rights risk to persons in care. Based on the review of R1’s Resident Assessment Results done on 03/01/2024, R1 needs to be provided staff escort to and from the activities. The facility staff failed to ensure R1 is provided escort after attending an activity inside the facility, which posed an immediate health, safety or personal rights risk to persons in care. LPA Jain conducted additional staff interview with S1 and reviewed additional documents - R1’s Progress notes, Activity Staff schedules, and in service all staff training for Elopement policy and procedures. A deficiency was cited under the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. See LIC 809-D page for more information. An immediate civil penalty of $500.00 was assessed today for the Absence of Supervision, which resulted in R1’s eloping from the facility. Failure to correct the deficiency may result in additional civil penalties. This report was reviewed with Executive Director, Li Li and a copy of this report along with the appeal rights was provided. A copy of the civil penalty was also provided.the state’s words, verbatim · CDSS document, Nov 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Nov 12, 2024

Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This was not met as evidence by: The facility staff failed to prevent resident (R1) from eloping the facility on 11/04/2024. R1 has dementia, is non-ambulatory due to mental condition, deemed not able to leave the facility unassisted, and was able to leave facility unassisted by the scheduled staff on 11/04/2024, which posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 12, 2024

Plan of correction: The Executive Director will develop a plan to ensure residents are being supervised at all times. Exectuive Director will provide a copy of the plan to CCL by 11/12/24. Immediate Civil Penalty of $500.00 is being assessed today 11/12/24 for the absence of supervision.

Type of visit: Case Management - Annual Continuation

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.the state’s words, verbatim · CDSS document, Jun 13, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Administrator Li Li. During visit, LPA Marrufo interviewed 5 residents and 5 staff as part of the annual inspection process. LPA Marrufo reviewed the first aid kit and found it to be complete. The last recorded fire drill was conducted on 05/31/2024. The facility records indicate the smoke detector system was tested monthly from January to May 2024. LPA Marrufo toured the kitchen area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. Due to time limitations, this inspection visit will need to be continued at a later time. 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.the state’s words, verbatim · CDSS document, Jun 11, 2024

Type of visit: Case Management - Incident

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.the state’s words, verbatim · CDSS document, May 23, 2024

Allegation investigated: Facility does not follow COVID-19 guidelines

On 4/18/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint inspection visit. LPA met with Executive Director, Li Li. The purpose of this visit is to deliver the finding of the investigation completed by the Department. During the visit, LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility. On 01/07/2022, the Department received a report alleging that facility does not follow COVID-19 guidelines. The Department conducted interviews and record reviews. Based on the information available, it was unable to prove whether the facility did not follow COVID-19 guidelines. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is unsubstantiated, at this time. No deficiencies were cited during the visit. Report is reviewed and copy is provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 18, 2024 · control 26-AS-20220107110340

Type of visit: Case Management - Incident

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 follow up on an Incident Report and Suspected Adult/Elderly Abuse Form (SOC341) submitted by the facility to CCL on 10/25/2023. The Incident Report and SOC341 stated that resident R1 had a witnessed fall on 10/22/2023. The reports stated staff S1 claimed that staff S2 did not report the truth when reporting the incident to R1's family member (FM1). The reports also state that S1 quit from being employed at the facility and left the facility. During visit, LPA Marrufo interviewed staff S2, FM1, and staff S3-S8. LPA Marrufo conducted an attempted interview with R1 and observed R1. S3 stated during interview to have assisted R1 when R1 was walking, but R1 began walking quickly and R1 fell face first in the facility hallway. S3 stated to have reported the incident to a nurse and medication technician at the time of the fall and observed staff reporting the fall incident to FM1. S3 stated FM1 arrived at the facility and S3 showed FM1 how R1 fell. During interview, S2 stated to have not neglected R1. S2 stated to have reported to S2 about R1's fall as well as what S2 found in S2's assessment of R1. FM1 stated during interview to not believe that staff were withholding information about R1's fall. Staff S4-S8 stated during interview to have not observed any incidents of staff neglecting residents. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Li Li and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 18, 2024