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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508359
Report Date: 12/02/2024
Date Signed: 12/02/2024 07:19:13 PM

Document Has Been Signed on 12/02/2024 07:19 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PENINSULA REGENT (THE)FACILITY NUMBER:
410508359
ADMINISTRATOR/
DIRECTOR:		MARTIN HERTERFACILITY TYPE:
741
ADDRESS:1 BALDWIN AVENUETELEPHONE:
(650) 579-5500
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 435TOTAL ENROLLED CHILDREN: 0CENSUS: 206DATE:
12/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Martin HerterTIME VISIT/
INSPECTION COMPLETED:
07:30 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. On the 11th floor, there is an activity room with piano, an art room, and 4 guest bedrooms for visiting overnight guests of residents. 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 118 degrees in room 117. Food supply, signal system, and first-aid kit are inspected. Emergency food supply consists of dehydrated canned food, which must be reconstituted with water. Facility maintains fresh water in 2 large capacity boilers on the roof.
"Stryker" evacuation chairs are maintained on the 6th floor stair landing, and there is an evacuation chair for each of 4 stairwells, according to Mr. Herter.
Some client and staff files are reviewed, and clients' medications are recorded on Centrally Stored Medications Records. 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. Martin Herter is a certified RCFE administrator (x 12/25) that oversees facility operations.

The following forms are requested to be completed and returned to CCL by 12/16/24:
• LIC 309 Administrative Organization for BASS Inc. and PRS Inc.
• LIC 500 Personnel Report
Updated Emergency Disaster Plan (LIC610E) is provided to LPA today.

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).
Deficiencies of the CA Code of REgulations, Title 22 are cited on a following page
April CowanTELEPHONE: (650) 266-8889
Audrey JeungTELEPHONE: (650) 266-8891
DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/02/2024 07:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: PENINSULA REGENT (THE)
FACILITY NUMBER: 410508359

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff record review, the licensee did not comply with the section cited above in 2 out of 6 staff files reviewed, which poses a potential health, safety or personal rights risk to persons in care.
Inspection Tool Notes:

- Health screenings and TB test results for staff #1 and #2 are not maintained.
POC Due Date: 12/16/2024
Plan of Correction
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Health screenings and TB test results for staff #1 and #2 will be sent to CCLD BY DUE DATE.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April CowanTELEPHONE: (650) 266-8889
Audrey JeungTELEPHONE: (650) 266-8891

DATE: 12/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/02/2024 07:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: PENINSULA REGENT (THE)
FACILITY NUMBER: 410508359

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff record review, the licensee did not comply with the section cited above, as there is no evidence that care staff have received required training on postural supports and restricted health conditions. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2024
Plan of Correction
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Staff shall receivd at least 4 hours of training on postural supports, restricted health conditions and hospice care annually, and proof of training shall be sent to CCLD BY DUE DATE.
Section Cited
Admission Agreements
(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. (1) The text of the admission agreement, including any attachments and modifications, shall be: (A) Printed in black type of not less than 12-point type size, on plain white paper. The print shall appear on one side of the paper only.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of clients' records, the licensee did not comply with the section cited above in 4 out of 6 files reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- Admission/residency agreements for clients #1, #2, #3, #5 are printed on both sides of paper.
POC Due Date: 12/16/2024
Plan of Correction
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Plan of correction to be submitted to CCLD BY DUE DATE, describing how admission/residency agreements will only be printed on one side of paper.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April CowanTELEPHONE: (650) 266-8889
Audrey JeungTELEPHONE: (650) 266-8891

DATE: 12/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/02/2024 07:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: PENINSULA REGENT (THE)
FACILITY NUMBER: 410508359

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
PERSONNEL REQUIREMENTS
Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of staff training records, the licensee did not comply with the section cited above in 2 out of 6 staff records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2024
Plan of Correction
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Proof of current first-aid training for staff #2 and #3 will 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.
April CowanTELEPHONE: (650) 266-8889
Audrey JeungTELEPHONE: (650) 266-8891

DATE: 12/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2024

LIC809 (FAS) - (06/04)
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