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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600976
Report Date: 08/05/2020
Date Signed: 08/05/2020 03:29:37 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PENINSULA REFLECTIONSFACILITY NUMBER:
415600976
ADMINISTRATOR:ANNA ALLASFACILITY TYPE:
740
ADDRESS:205 COLLINS AVETELEPHONE:
(650) 731-4670
CITY:COLMASTATE: CAZIP CODE:
94014
CAPACITY:57CENSUS: 30DATE:
08/05/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Anna Allas, AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Raygoza made a case management visit via Virtual face time with Ana Allas, Administrator and stated purpose of visit.

LPA Raygoza inquired regarding Incident occurrence of 7/25/20 involving Colma Police Department bringing R1 back to facility. R1 sustained no injuries and was walked back safely to community by Colma Police Department. Resident all the while with a caregiver 1:1. Plan of care in place to be submitted to CCL Office on preventing reoccurring incidents on resident's eloping.

This report was discussed and a copy provided to Anna Allas, Administrator.

No Deficiency Cited.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha RaygozaTELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2020
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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