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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600976
Report Date: 12/20/2024
Date Signed: 12/20/2024 12:43:06 PM

Document Has Been Signed on 12/20/2024 12:43 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 REFLECTIONSFACILITY NUMBER:
415600976
ADMINISTRATOR/
DIRECTOR:
ANNA ALLASFACILITY TYPE:
740
ADDRESS:205 COLLINS AVETELEPHONE:
(650) 731-4670
CITY:COLMASTATE: CAZIP CODE:
94014
CAPACITY: 57TOTAL ENROLLED CHILDREN: 0CENSUS: 40DATE:
12/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Activities Director, Nancy MedinaTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On December 20, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit in relation to an incident that occurred on 12/6/24. LPA met with Activities Director, Nancy Medina and explained the purpose of the visit.

The Licensee reported on 12/6/24, Resident 1 (R1) reported that Staff 1 (S1) threw a call light at him/her and his his/her head. According to R1, he/she told S1 that he/she will report S1 to the facility. S1 told R1 that if he/she reported S1 to the facility, he/she will kill R1. 911 was called.

The facility assessed R1 for any visible injuries. No injuries were notes. Facility spoke to R1's responsible party who indicated that R1 says things like that even when R1 was at home. In addition, R1's responsible party indicated that whatever R1 said did not happen.

During the visit, LPA attempted to interview R1, reviewed R1's file and interviewed the Activities Director. According to the Activities Director, this was an alleged incident and the facility found no evidence to prove that S1 actually did hit R1 with a call light. In addition, according to the Activities Director, R1 has dementia.

LPA reviewed R1's file. Based on documentation reviewed, R1 has a diagnosis of dementia, and gets confused, aggressive and has inappropriate behaviors. LPA attempted to interview R1 but due to the language barrier and dementia diagnosis, LPA was not able to get much information from R1. R1 mentioned he likes the staff here and does not have many issues at this facility.

No citations are issued during the visit. LPA reviewed report with the Activities Director and a copy is provided.
April CowanTELEPHONE: (650) 266-8889
Komal CharitraTELEPHONE: (650) 629-4305
DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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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