415600976-11-5-2025-14-AS-ACON-DNHV83-20251117151202

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600976
Report Date: 11/05/2025
Date Signed: 11/05/2025 01:49:03 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/22/2025 and conducted by Evaluator Komal Curley

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20250722131624

FACILITY NAME:	PENINSULA REFLECTIONS		FACILITY NUMBER:	415600976
ADMINISTRATOR:	ANNA ALLAS		FACILITY TYPE:	740
ADDRESS:	205 COLLINS AVE		TELEPHONE:	(650) 731-4670
CITY:	COLMA	STATE: CA	ZIP CODE:	94014
CAPACITY:	57	CENSUS: 35	DATE:	11/05/2025
		UNANNOUNCED	TIME BEGAN:	10:58 AM
MET WITH:	Administrator, Anna Allas		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Due to staff neglect, resident sustained a pressure injury
Staff retained a resident with a prohibited health condition
Staff did not notify authorized representative of change in condition

INVESTIGATION FINDINGS:

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On November 5, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Anna Allas and explained the purpose of the visit.

Regarding the allegation, due to staff neglect, resident sustained a pressure injury in care, according to the reporting party, on May 14, 2025, a Registered Nurse (RN) from Home Health found pressure wounds on Resident 1’s (R1’s) feet and an open Stage IV sacral pressure wound. The facility’s LVN was educated on wound care and staff were reminded to ensure R1 is being repositioned and monitored for hydration and eating for wound healing and overall health, however according to reporting party it was observed that R1 sat in a wheelchair for 6-8 hours a day before the wound was reported on May 14, 2025.

During the investigation, LPA interviewed the administrator, staff, reviewed R1’s file; including but not limited to, service plan, home health notes, hospice notes, charting notes, repositioning log, etc. According to the administrator, when R1 was admitted to the facility, R1 did not have any wounds or pressure injuries, however there was redness on R1’s sacrum that was noted. (continue to 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 14-AS-20250722131624

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PENINSULA REFLECTIONS	FACILITY NUMBER: 415600976
	VISIT DATE: 11/05/2025

NARRATIVE

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On 3/16/25, a nurse from Sutter Care Home came to assess R1 for the appropriate services that's required for R1's needs. Based on the nurse's assessment from Sutter Care, R1 was admitted to hospice on 3/22/25.
R1's responsible party revoked hospice services on 4/6/25. Starting 4/1/25, home health started visiting R1 for physical therapy and continued to come 1-2x a week for leg exercises. Based on R1's progress notes reviewed, on 5/9/25, the facility observed an open wound on R1's sacrum. The facility notified R1's physician and the physician ordered home health to evaluate R1's wound. On 5/14/25, R1 was assessed by Sutter Care at Home who indicated that R1 had a pressure ulcer to sacrum. According to staff interviewed, the facility notified R1's physician, responsible party, and updated R1's care plan. Based on R1's care plan, the facility repositioned R1 every two hours, followed the treatment plan that was provided by home health, and monitored R1 for any changes of condition. In addition, home health was coming 2-3x a week for wound care. Based on the repositioning log, R1 was being repositioned every two hours. According to interviews conducted, med-techs were instructed to call hospice when R1's dressing needed to be changed or was soiled if the facility LVN was not present at the facility. In addition, according to the administrator, R1 had a one-on-one caregiver 24/7 who was also trained to change R1's dressing.

Regarding the allegation, staff retained a resident with a prohibited health condition, according to the reporting party, on 5/14/25, R1 was found to have an open stage IV sacral pressure wound.

During the investigation, LPA interviewed the administrator and reviewed R1’s file. According to documents reviewed, on 5/23/25, a wound nurse came to visit R1 and determined R1's sacral wound was unstageable. According to the Department's and facility's records reviewed, after the administrator was notified that the sacrum pressure injury was unstageable on 5/23/25, an exception request was submitted to Community Care Licensing the same day to request for the facility to continue providing care to R1 who had a prohibited health condition.

Regarding the allegation, staff did not notify authorized representative of change in condition, on May 14, 2025, it was found that R1 had pressure wounds on his/her feet and an open stage IV sacral pressure wound, however R1’s authorized representative was not notified about the wound until May 21, 2025.

(Continue to 9099C)

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20250722131624

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PENINSULA REFLECTIONS	FACILITY NUMBER: 415600976
	VISIT DATE: 11/05/2025

NARRATIVE

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During the investigation, LPA interviewed the administrator, reviewed home health notes, R1's charting notes, progress notes, and service plan. Based on home health document dated 5/14/25, R1 was observed to have a pressure ulcer to the sacrum. According to the administrator and service plan reviewed dated 5/14/25, the LVN updated the service plan due to change of condition, in specific to active pressure ulcer on heel and sacrum. Based on the progress reports and charting notes reviewed, R1's responsible party was contacted on 5/16/25 regarding the presence of the sacral wound.

Based on interviews conducted, documents reviewed, and information collected, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED.

Report is reviewed with the administrator and a copy is provided.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025

LIC9099 (FAS) - (06/04)

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