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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600593
Report Date: 07/28/2022
Date Signed: 07/28/2022 04:48:13 PM


Document Has Been Signed on 07/28/2022 04:48 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:PENINSULA VILLAGEFACILITY NUMBER:
415600593
ADMINISTRATOR:RAMOS, ANDREWFACILITY TYPE:
740
ADDRESS:108 E. HILLSDALE BLVD.TELEPHONE:
(650) 345-1357
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 4DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Terry IllastronTIME COMPLETED:
05:00 PM
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LPA Audrey Jeung toured facility and grounds of this 1-level home, consisting of 6 client bedrooms and a staff bedroom--each with a private half bathroom--and a shower room, kitchen, living, and dining rooms. There is an enclosed patio and backyard. There is a 1 car garage, where washer and dryer are located. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars, nonskid flooring material, hand washing reminder signs, and liquid soap. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 4 residents present, and 3 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as health screenings. Staff have current first-aid training. Terry Illastron is a certified RCFE administrator (x 12/23) that oversees facility operations.

The following updated forms/information are requested to be submitted to CCLD BY 8/11/22:

• Current lease agreement (This was not submitted as requested in 2021)
• Current liability insurance
• LIC 9282 Infection Control Plan

No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed.. See 2 Technical Advisory Notes for additional information.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
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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