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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600976
Report Date: 09/30/2024
Date Signed: 09/30/2024 02:06:48 PM

Document Has Been Signed on 09/30/2024 02:06 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: 41DATE:
09/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Activities Director, Nancy MedinaTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On September 30, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit to follow up on an incident that occurred on 9/21/24. LPA met with Activities Director, Nancy Medina and explained the purpose of the visit.

On September 24, 2024, Licensee reported that Resident 1 (R1) was found outside along the driveway of the facility. According to the Licensee, a bystander observed R1 climbing the metal gate and was able to get out. Bystander was trying to redirect R1 until staff came out to get R1. Skin abrasions were noted.

During the visit today, LPA conducted interviews and reviewed R1's file. According to file reviewed, R1 has a diagnosis of Alzheimer's Dementia and is unable to leave the facility unassisted. LPA did not observe any reappraisal for R1 after R1 eloped on 9/21/24. In addition, during the file review, LPA observed that R1's physician's report is dated from 2/28/23. Facility failed to ensure an updated annual medical assessment/ physician's report is maintained in R1's file.

According to the Administrator, R1 used the exit door in the dining room and gained access to the courtyard and climbed up the metal gate. In addition, the administrator was unable to provide information on why the staff didn't hear the auditory alarm when R1 opened the exit door and why staff was unable to respond immediately. Based on staff interviewed, it was indicated that staff were assisting other residents and was unable to respond immediately. During the visit today, LPA opened the exit door in the dining room to ensure alarms were on and functioning. It was observed the alarm was on and in good repair.

Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page. Report is reviewed with Activities Director and a copy is provided with appeal rights.
April CowanTELEPHONE: (650) 266-8889
Komal CharitraTELEPHONE: (650) 629-4305
DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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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Document Has Been Signed on 09/30/2024 02:06 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Section Cited
87464 Basic Services (f)- Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).

Violation of this regulation is not met as evidenced by:
Deficient Practice Statement
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POC Due Date: 10/07/2024
Plan of Correction
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Facility will conduct in-service training with staff regarding elopmenet protocols and submit a copy of the training log to LPA by 10/7/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April CowanTELEPHONE: (650) 266-8889
Komal CharitraTELEPHONE: (650) 629-4305

DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024

LIC809 (FAS) - (06/04)
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