Community Care Licensing

Document Has Been Signed on 06/18/2024 02:36 PM - It Cannot Be Edited

FACILITY NAME:	PENINSULA VILLAGE		FACILITY NUMBER:	415600593
ADMINISTRATOR/ DIRECTOR:	RAMOS, ANDREW		FACILITY TYPE:	740
ADDRESS:	108 E. HILLSDALE BLVD.		TELEPHONE:	(650) 345-1357
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY: 6		CENSUS: 6	DATE:	06/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Terry Illastron		TIME VISIT/ INSPECTION COMPLETED:	02:30 PM

SUPERVISORS NAME: April Cowan LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024

Link to Parent Document Below:

FACILITY NAME: PENINSULA VILLAGE	FACILITY NUMBER: 415600593
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2024

Type B

Section Cited

CCR

87470(c)

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and confirmation from administrator, the licensee did not comply with the section cited above, as an Infection Control Plan has not been developed. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/02/2024
	Plan of Correction
1 2 3 4	Infection Control Plan (LIC9282) will be completed and submitted to CCLD BY DUE DATE.

Type B

Section Cited

HSC

1569.625(b)(2)

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on confirmation from administrator and absence of documentation, the licensee did not comply with the section cited above, as there is no evidence that staff have received required annual training, including dementia, postural supports, restricted health conditions, hospice care. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/02/2024
	Plan of Correction
1 2 3 4	Staff shall receive at least 20 hours of continuing training, with shall include at least 8 hours of dementia training and 4 hours on postural supports, restricted health conditions, and hospice care. Proof of training shall be submitted to CCLD BY DUE DATE.

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024

Link to Parent Document Below:

FACILITY NAME: PENINSULA VILLAGE	FACILITY NUMBER: 415600593
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2024

Type B

Section Cited

HSC

1569.267(d)

(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on confirmation from administrator and absence of training documentation, the licensee did not comply with the section cited above, as there is no evidence that any staff have received annual training on residents' personal rights, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/02/2024
	Plan of Correction
1 2 3 4	Proof that staff received annual personal rights training will be sent to CCLD BY DUE DATE.

Type B

Section Cited

CCR

87458(b)(1)

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of client records, the licensee did not comply with the section cited above, as MD report for client #2 does not include diagnoses, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/02/2024
	Plan of Correction
1 2 3 4	Complete MD report for client #2 shall be submitted to CCLD BY DUE DATE. Diagnoses must be stated on report.

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024

Link to Parent Document Below:

FACILITY NAME: PENINSULA VILLAGE	FACILITY NUMBER: 415600593
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2024

Type B

Section Cited

CCR

87463(a)

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on clients record review, the licensee did not comply with the section cited above in 2 out of 6 files reviewed. Appraisal for client #2 is dated 10/2017 and must be updated No appraisal for client #3. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/02/2024
	Plan of Correction
1 2 3 4	Updated appraisals for clients #2 and #3 will be submitted to CCLD BY DUE DATE.

Type B

Section Cited

HSC

1569.695(b)

(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on confirmation from administrator and absence of training records, the licensee did not comply with the section cited above, as all staff have not received ongoing training on responding to emergencies and disasters. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/02/2024
	Plan of Correction
1 2 3 4	Staff shall receive training on responding to emergencies and disasters, and documentation of training shall be sent to CCLD BY DUE DATE.

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024

Link to Parent Document Below:

FACILITY NAME: PENINSULA VILLAGE	FACILITY NUMBER: 415600593
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2024

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on confirmation from administrator and absence of documentation, the licensee did not comply with the section cited above, as there is no documentation that disaster or emergency drills have been conducted quarterly. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/02/2024
	Plan of Correction
1 2 3 4	Disaster drills shall be performed at least quarterly and documented. Proof of correction shall be sent to CCLD BY DUE DATE.

Type B

Section Cited

CCR

87465(h)(6)

INCIDENTAL MEDICAL CARE 87465 (h)(6) A record of centrally stored prescription medications for each resident shall be maintained and include names of the resident for whom prescribed, prescribing physician and pharmacist, drug name, strength and quantity, dates filled, started & expiration, prescription number and instructions: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review medications and Centrally Stored Medications Records for clients #3 and #5, the licensee did not comply with the section cited above, as dates are inaccurate and incomplete, strength is not legible, Rx numbers are not recorded, some Rx medications are not recorded on CSMRs. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/02/2024
	Plan of Correction
1 2 3 4	Proof that all clients' medications are logged accurately on Centrally Stored Medications Records will be sent to CCLD BY DUE DATE.

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024

Link to Parent Document Below:

FACILITY NAME: PENINSULA VILLAGE	FACILITY NUMBER: 415600593
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2024

Type B

Section Cited

CCR

87303(a)

MAINTENANCE AND OPERATION The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as discarded commodes, furniture, wheelchair, mattresses are stored in backyard, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/02/2024
	Plan of Correction
1 2 3 4	Backyard will be free of discarded furnishings. Proof of correction to be sent to CCLD BY DUE DATE.

Type B

Section Cited

CCR

87705(c)(5)

CARE OF PERSONS WITH DEMENTIA Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on client record review, the licensee did not comply with the section cited above, as client #1 is diagnosed with dementia, but MD report and appraisal are 5 years old. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/02/2024
	Plan of Correction
1 2 3 4	Updated MD report and appraisal for client #1 will be sent to CCLD BY DUE DATE.

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024