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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508359
Report Date: 11/20/2025
Date Signed: 11/20/2025 06:43:00 PM

Document Has Been Signed on 11/20/2025 06:43 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: 435CENSUS: 216DATE:
11/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Martin Herter & Leona MartinTIME VISIT/
INSPECTION COMPLETED:
06:45 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds of this Continuing Care Retirement Community, which is 11 stories tall and accommodates independent residents and assisted living residents in 20 units on the ground floor. There is an activity room with piano, an art room, and 4 guest bedrooms for visiting overnight guests of residents on the 11th 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. Common areas on the ground floor include beauty salon, game room, fitness room and library. There are no fire safety hazards observed. Hot water temperature is tested at 116 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 supply of fresh water in addition to 2 large capacity boilers on the roof. Reports of quarterly consultations by registered dietician are maintained,
Fire and emergency drills are documented and occur at least quarterly. "Stryker" evacuation chairs are maintained on the 6th floor stair landings; there is an evacuation chair for each of 4 stairwells.
Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as required staff records. Martin Herter is a certified RCFE administrator (x 12/25) that oversees facility operations. Resident records will be reviewed at a later date--including Centrally Stored Medications Records--due to time constraints. Three residents are receiving hospice services at this time. An updated Disaster and Mass Casualty Plan is readily available.

The following forms are requested to be completed and returned to CCL by 12/4/25:
• LIC 309 Administrative Organization for BASS Inc. and PRS Inc.
• LIC 500 Personnel Report

Deficiencies of the California Code of Regulations, Title 22 are observed and cited on following pages.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 11/20/2025 06:43 PM - It Cannot Be Edited


Created By: Audrey Jeung On 11/20/2025 at 06:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/21/2025
Section Cited
CCR
87411(g)(1)

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PERSONNEL REQUIREMENTS - GENL
Prior to employment or initial presence in the facility, all employees... subject to a criminal record review shall obtain a CA clearance or a criminal record exemption as required by law or Dept. regulations. This requirement is not met, as dining server staff #1 does not
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Staff #1 will obtain criminal record clearance and proof of correction will be sent to CCLD BY DUE DATE
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have criminal record clearance and is 18 years old. Licensee failed to ensure that all employees with direct client contact maintain criminal record clearance, whish poses an immediate health, safety or personal rights risk to clients in care.
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Type A
11/20/2025
Section Cited
CCR87465(h)(2)

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INCIDENTAL MEDICAL CARE
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met, as OTC meds
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Advil and Tylenol were removed from room 116 in LPA's presence and 3 bottles of Fiber Gummies were removed from room 101 during LPA's visit.
Deficiency corrected and cleared
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& supplements are stored in 2 assisted living apartments, which are occupied by clients who are unable to safely store & administer their medications. Licensee failed to ensure that medications are inaccessible to residents who are unable to store their medications, posing an immediate health and safety risk.
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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 Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2025


LIC809 (FAS) - (06/04)
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