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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508747
Report Date: 05/24/2021
Date Signed: 05/24/2021 11:12:41 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:PENISONI CARE HOMEFACILITY NUMBER:
410508747
ADMINISTRATOR:PENISONI, KOLOTINA L.FACILITY TYPE:
740
ADDRESS:2736 GEORGETOWN STREETTELEPHONE:
(650) 323-5844
CITY:EAST PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:9CENSUS: 7DATE:
05/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sione PenisoniTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Infection Control visit and met with Sione Penisoni.

During visit, LPA Marrufo toured the kitchen area, 4 out of 4 bedrooms, and 2 out of 2 bathrooms, living room area, hallways, and the outdoor area.

LPA observed the visitor entryway does not have a screening log to record visitor symptoms and temperatures. Facility observed to have an adequate supply of PPEs.

Two Advisory Notes were issued. See LIC9102 for more information.

No deficiencies were cited as per California Code of Regulations Title 22.


This report was reviewed with Sione Penisoni and a copy of the report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021
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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