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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508747
Report Date: 03/04/2025
Date Signed: 03/04/2025 01:26:50 PM

Document Has Been Signed on 03/04/2025 01:26 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PENISONI CARE HOMEFACILITY NUMBER:
410508747
ADMINISTRATOR/
DIRECTOR:		PENISONI, KOLOTINA L.FACILITY TYPE:
740
ADDRESS:2736 GEORGETOWN STREETTELEPHONE:
(650) 323-5844
CITY:EAST PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY: 9TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
03/04/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Sione PenisoniTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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On March 04, 2025, at 12:15 PM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Other inspection visit. Upon arrival, the LPA was greeted by the Sione Penisoni, husband (FM1) and niece (FM2) of the Licensee, Kolotina Penisoni. The LPA disclosed the purpose of the visit. There were four (4) residents at the facility.

The Licensee passed away on 02/01/2025. The property and the facility’s license were under the Licensee’s name. The department was not notified on the licensee’s death. FM1 continued to provide care and supervision to four (4) residents after the passing of the licensee.

FM1 stated that the licensee left no will or family trust to designate or transfer the property to FM1. FM1 was planning to go to the court to get the property under their name.

FM2 stated that 3 of 4 residents were placed at the facility through Telecare housing coordinator (HC) and 1 of 4 residents was placed by San Mateo County case worker (CW).

LPA reviewed resident records for four (4) residents.

The facility is currently operating as un-licensed and cannot continue to provide care and supervision to all four (4) residents. LPA advised FM1 and FM2 to immediately start relocating four (4) residents (R1-R4) and work with resident’s families, LTCO, county case worker, and Telecare housing coordinators to relocate all (4) residents.

LPA asked FM1 and FM2 to keep the LPA updated on the relocation progress of all four (4) residents. FM1 showed interest in applying for the license. LPA advised that in future they could apply for the license from the department if they have the control of the property.

No deficiencies were cited during today's visit.

An exit interview was conducted with the licensee’s family member (FM1). A copy of this report was left with the FM1, whose signature on this form confirms receipt of the report.

April CowanTELEPHONE: (650) 266-8889
Kiran JainTELEPHONE: (650) 416-4836
DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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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