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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600976
Report Date: 10/26/2021
Date Signed: 10/26/2021 12:15:17 PM

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: 37DATE:
10/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Kathy Nguyen, LVNTIME COMPLETED:
12:30 PM
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On October 26, 2021, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA was screened at the front entrance but did not see COVID-19 signage at the front door. LPA was greeted by LVN, Kathy Nguyen. LPA explained the purpose of the visit. LVN was able to provide LPA with a daily resident and staff temperature log as well as a visitor log.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, containment strategies, PPE supply and the environmental cleaning supply are adequate. COVID-19 signs were observed throughout the facility but LPA recommends more reminder signage to be posted in the hallways on first and second floor, and the front door. The beds in the semi-private rooms are observed to be 6 feet apart.

All bathrooms are equipped with non-skid mats, liquid soap and paper towels. LPA advises to cover all trash bins with lids and add hand-washing signs in all bathrooms including residents. LPA observed the residents in the activities room to be social distancing. Dining room was observed to have tables and chairs distanced enough to maintain COVID-19 social distancing protocols.

Medications, toxins and sharps are stored appropriately and inaccessible to resident, and a comfortable temperature is maintained, lighting is sufficient for comfort.

According to the LVN all staff and residents are vaccinated.

LPA requested for the following documents to be submitted to CCLD by 11/2/2021.
-LIC 308
-LIC500
-Administrator Certificate
-LIC610E
-LIC402
-Surety Bond

This report is reviewed with LVN, Kathy Nguyen and a copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
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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