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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508747
Report Date: 05/09/2022
Date Signed: 05/09/2022 04:14:50 PM


Document Has Been Signed on 05/09/2022 04:14 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



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: 9DATE:
05/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Mary LatuTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Requred 1 Year Visit and met with Sionne Penisoni.

During visit, LPA Marrufo observed that there was no visitor screening log. LPA Marrufo toured 2 out of 2 bathrooms and observed that there were no hand washing signs in the bathroom. LPA Marrufo requested to see the PPE supplies and observed there to be 1 box of 100 pairs of gloves and a box of 100 hand sanitizing wipes. Staff Mary Latu stated that the facility did not have surgical masks or N95 masks.

LPA Marrufo toured the facility inside and out. LPA Marrufo toured 5 out of 5 resident bedrooms and 2 out of 2 bathrooms. LPA Marrufo toured the outside area and found the exits to be clear of obstructions.

LIC9102 Technical Assistance Advisory Notes were issued.


This report was reviewed with Sionne 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: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
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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