415600976-9-17-2024-14-AS-KJAN-D97R53-20240917124228

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600976
Report Date: 09/17/2024
Date Signed: 09/17/2024 12:42:38 PM

Document Has Been Signed on 09/17/2024 12:42 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

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: 41	DATE:	09/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Anna Allas, Administrator		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On September 17, 2024, Licensing Program Analysts (LPAs) Kiran Jain and Komal Charitra arrived at the facility at 09:15 AM to conduct the Annual 1-year required inspection. LPAs met with Nancy Medina, Activity Director and explained the purpose of the visit. Anna Allas, Administrator joined shortly after. LPAs toured the physical plant and observed it to be clean and odor-free at a comfortable temperature. This is a two-story building with 21 resident bedrooms, 21 bathrooms, a dining room, a living room, an activity area, a storage/supply room, a kitchen, a laundry room, a medication room, and offices on the first level. The second level has 13 resident bedrooms, 13 bathrooms, storage rooms, and a spa room. Delayed Egress was observed to be working properly at the main entrance door. Auditory devices were observed to be in place to monitor all exits. No accessible bodies of water or hazards were observed. Video surveillance was observed only in the hallways and common areas of the facility. The fire extinguishers were fully charged and last serviced on April 2024. The smoke detector and carbon monoxide detector were fully operational. LPAs inspected resident’s rooms and bathrooms at random. Rooms were observed to be clean with the required furniture and sufficient lighting. The bathrooms were observed to be mold-free and equipped with grab bars, liquid soap, and paper towels. The hot water temperature in the resident's bathroom was measured on the first floor in room 10 at 108.6°F. Hot water temperature was also measured on the second floor in room 23 at 118.4°F. Sharp objects, detergents, poisons, and soap were observed to be locked and inaccessible to persons in care. No expired food items were observed. The facility had the required 7 days of non-perishables and 2 days of perishables.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran Jain	TELEPHONE: 650-416-4836
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/17/2024

NARRATIVE

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LPAs reviewed five resident records and five staff records. All were observed to be complete. Emergency drills are conducted monthly with the last drill documented on September 2024.

The resident’s medications are securely stored in a locked cart/cabinet/refrigerator. Medication administration records (MARs) were reviewed, and no expired medications were observed. The First Aid kit was checked and observed to be complete.

The following updated forms are requested to be submitted to CCLD by 09/24/2024:

· LIC500: Personnel Report
· LIC308: Designation of Facility Responsibility
· LIC400: Resident Cash Resources
· Administrator Certificate
· Current Liability Insurance

No deficiencies were cited during today's visit.

An exit interview was conducted. This report was reviewed with Anna Allas, Administrator, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran Jain	TELEPHONE: 650-416-4836
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC809 (FAS) - (06/04)

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