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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508747
Report Date: 05/20/2024
Date Signed: 05/20/2024 11:44:40 AM


Document Has Been Signed on 05/20/2024 11:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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: 2DATE:
05/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sione PenisoniTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Sione Penisoni.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the kitchen area and observed there to be a perishable food supply of 2 days and a non-perishable food supply of at least 7 days. LPA Marrufo reviewed the first aid kit and observed it to be complete.

LPA Marrufo toured the resident bathroom in the hallway and observed the water temperature to be 106 F. The bathroom had available paper towels and working lights.

LPA Marrufo toured 5 out of 5 bedrooms and each bedroom had available bedding and clothing storage areas. LPA Marrufo tested the smoke detectors in each bedroom and hallway as well as two out of two carbon monoxide detectors; all detectors functioned properly when tested.

LPA Marrufo toured the outside area and found the exits to be clear of obstructions.

LPA Marrufo reviewed the resident and staff records. Resident R1 and R2 were missing their Centrally Stored Medication Logs and R1 was missing an Identification and Emergency Information Form. Staff S1 was missing a 1st Aid Certification.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information.

This report was reviewed with Sione Penisoni and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 05/20/2024 11:44 AM - 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: PENISONI CARE HOME
FACILITY NUMBER: 410508747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(14)
87506 (b) Each resident’s record shall contain at least the following information: (14) Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services

This requirement is not met as evidenced by:
Deficient Practice Statement
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During records review, two out of two residents did not have Centrally Stored Medication and Destruction Records in their resident records, which poses a potential safety risk to residents in care.
POC Due Date: 05/27/2024
Plan of Correction
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Licensee agrees to submit copies of completed Centrally Stored Medication and Destruction Records for 2 out of 2 residents to CCL by POC date.
Type B
Section Cited
CCR
87411(c)(1)
87411 (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) 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 records review, LPA Marrufo observed 1 out of 2 staff did not have a first aid certification on record, which poses a potential safety risk to residents in care.
POC Due Date: 05/27/2024
Plan of Correction
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Licensee agrees to submit a copy of staff S1's current first aid certification to CCL by POC 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.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 05/20/2024 11:44 AM - 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: PENISONI CARE HOME
FACILITY NUMBER: 410508747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(9)
87506 (b) Each resident’s record shall contain at least the following information: (9) Name, address and telephone number of physician and dentist to be called in an emergency.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
During record review, LPA Marrufo observed that 1 out of 2 residents did not have an Emergency Identification and Information form, which poses a potential safety risk to residents in care.
POC Due Date: 05/27/2024
Plan of Correction
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2
3
4
Licensee agrees to submit a copy of resident R1's completed Emergency Identification and Information Form to CCL by POC date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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2
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3