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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508359
Report Date: 12/16/2019
Date Signed: 12/16/2019 07:11:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PENINSULA REGENT (THE)FACILITY NUMBER:
410508359
ADMINISTRATOR:MARIANNE NANNESTADFACILITY TYPE:
741
ADDRESS:1 BALDWIN AVENUETELEPHONE:
(650) 579-5500
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:435CENSUS: 230DATE:
12/16/2019
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Elizabeth GuilhotTIME COMPLETED:
07:00 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds of this Continuing Care Retirement Community. Building consists of 11 stories, with 20 assisted living units on the ground floor. There is a covered swimming pool and jacuzzi tub, as well as a shallow pond on premises. Pool and jacuzzi can be accessed by a door fob issued to independent residents only. There are no fire safety hazards observed. Toxins and sharps are stored appropriately and inaccessible to clients, and lighting is sufficient for comfort and safety. Hot water temperature is tested at 115 degrees in room 110. Food supply, signal system, and first-aid kit are inspected. Some client files are reviewed. An updated Disaster and Mass Casualty Plan is readily available. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff training records. Marianne Nannestad is a certified RCFE administrator (x9/18) that oversees facility operations.

The following form is to be completed and returned to CCL by 1/6/2020:
• LIC 309 Administrative Organization

PUB474, pertaining to resident councils (per AB1572) is posted, as are text of Health and Safety Code 1569.269 AND CCR Title 22 Section 87468 (Personal Rights form LIC613C) (per AB2171) and CCLD Hotline information (per SB895).

Deficiency of the CA Code of REgulations, Title 22 is cited on a following page.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2019
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PENINSULA REGENT (THE)
FACILITY NUMBER: 410508359
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(17)
In facilities licensed for 50 or more, and providing 3 meals/day, a full-time employee qualified by formal training or experience shall be responsible for the oepration of the food service. If this person is not a nutritionist, a dietician, or a home economist, provision shall be made for regular consultation from a person so qualified. The consultation services shall be provided during at least one meal. A written record of the frequency, nature, and duration of the consultant's visits shall be secured from the consultant and kept on file in the facility.

This requirement is not met as evidenced by absence of facility nutritionist, dietician or home economist and no consultation review by dietician done in past 2 years.
Deficient Practice Statement
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Based on absence of food consultation review and admission from administrator, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2020
Plan of Correction
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Food/dietician consultant review shall be conducted and copy of report shall be sent to CCLD BY DUE DATE.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2019
LIC809 (FAS) - (06/04)
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