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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508359
Report Date: 10/06/2022
Date Signed: 10/06/2022 03:39:00 PM


Document Has Been Signed on 10/06/2022 03:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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: 196DATE:
10/06/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Leona MartinTIME COMPLETED:
03:45 PM
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LPA Jeung and LPM Smith met with director of health and wellness in response to Death Report submitted on 10/4/22. Admission agreement for client was provided, as well as information regarding facility monitoring of independent residents.

Staff schedule and client rosters are obtained.

No deficiencies cited today.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022
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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