415600976-12-5-2025-14-AS-ACON-DPB3QC-20251212172656

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600976
Report Date: 12/05/2025
Date Signed: 12/05/2025 01:34:18 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
07/01/2025 and conducted by Evaluator Komal Curley

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20250701130341

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:	12/05/2025
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Activities Director, Nancy Medina		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff did not answer residents calls for assistance
Staff could not communicate with emergency personnel
Staff did not have access to residents emergency paperwork for Emergency personnel

INVESTIGATION FINDINGS:

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On December 5, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Activities Director, Nancy Medina and explained the purpose of the visit.

Regarding the allegation, staff did not answer residents call for assistance, according to the reporting party, on June 16, 2025, emergency personnel responded to the facility for a resident (R1) complaining of body pain. According to the reporting party, when emergency personnel responded to the facility and went to the second floor, there were no staff member to be seen and R1 was yelling for yelp. In addition, reporting party indicated that R1 was yelling for help for over two hours with no staff attending R1's needs.

During the investigation, LPA interviewed the staff on shift that night. According to Staff 1 (S1), he/she worked on the second floor, Staff 2 (S2) worked on the first floor and Staff 3 (S3) was working on both floors. S1 and S2 indicated that they did not hear R1 yelling for help. S1 stated that R1 was on his/her cell phone when he/she checked on R1. (continue to 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025

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

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20250701130341

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: 12/05/2025

NARRATIVE

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In addition, S1 and S3 indicated that R1 wanted his/her medication, however they had to keep explaining to R1 that the medication he/she was requesting for is prescribed to be given once every 8 hours, however they made sure that R1 was being checked on every 1-2 hours.

Regarding the allegation, staff could not communicate with emergency personnel, according to the reporting party, on June 16, 2025, when emergency personnel arrived to the facility, they requested R1's paperwork, however the staff was Spanish speaking only and radioed another staff member.

During the investigation, LPA interviewed staff who were on shift on June 16, 2025. According to Staff 1 (S1), when emergency personnel arrived, S1 admitted he/she had to call S3, the med-tech on shift because S1 speaks Spanish and very little English. In addition, according to 3/3 staff interviewed, although they do not speak a lot of English, they are able to communicate and understand basic English.

Regarding the allegation, staff did not have access to residents emergency paperwork for emergency personnel, according to the reporting party, on June 16, 2025, when emergency personnel responded to the facility, they requested for R1's file, however after 10 minutes of waiting, a firefighter went to the staff to see where the file was and was told by staff that they were on the phone with someone (unknown) trying to figure out to to get R1's file.

During the investigation, LPA interviewed staff on shift and observed the med-tech room where all resident files are located. Based on observations, LPA observed all resident files available and located in the med-tech office room. According to S3, he/she indicated that normally when staff call 911, the updated system papers are printed and ready for emergency personnel, however, the night of June 16, 2025, R1 called 911 without staff knowing and the papers were not ready so S3 had to go to the med-tech room and print R1's paperwork which took some time as the S3 indicated he/she was experiencing printer issues. According to S3, although it took time to print R1's paperwork, it was eventually printed and provided to emergency personnel.

Based on interviews conducted 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 Activities Director and a copy is provided.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025

LIC9099 (FAS) - (06/04)

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