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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600976
Report Date: 03/12/2021
Date Signed: 03/15/2021 08:17:39 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PENINSULA REFLECTIONSFACILITY NUMBER:
415600976
ADMINISTRATOR:ANNA ALLASFACILITY TYPE:
740
ADDRESS:205 COLLINS AVETELEPHONE:
(650) 731-4670
CITY:COLMASTATE: CAZIP CODE:
94014
CAPACITY:57CENSUS: 40DATE:
03/12/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Anna Allas, AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Raygoza made a case management visit via Virtual face time with Anna Allas, Administrator and stated purpose of visit.

LPA Raygoza conducted a virtual visit regarding Incident occurrence of R1 able to elope on 3/6/21. R1 was able to elope and returned to facility with no injury. Police and Paramedics arrived to assist. Family and social worker contacted.

During tour of area of elopement, there was a temporary alarm placement observed. According to Administrator a new alarm was ordered and to be installed. The fence will be made higher and welder has been contracted. Currently, R1 as part of care plan is being checked every 30 min. Plan in place to be submitted to CCL Office for non-reoccurrence of incident.

This report was discussed and a copy provided to Anna Allas, Administrator.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha RaygozaTELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021
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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