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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600976
Report Date: 10/14/2022
Date Signed: 10/14/2022 02:12:02 PM


Document Has Been Signed on 10/14/2022 02:12 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
SF COASTAL AC/SC, 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: 39DATE:
10/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Anna AllasTIME COMPLETED:
02:20 PM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with administrator Anna Allas and explained purpose of today's visit.

LPA conducted a tour of the facility's physical plant and grounds. There are no accessible bodies of water or fire safety hazards are observed. Infection control practices are reviewed: Entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate and infection control signs are posted prominently. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained measured at 70F, and lighting is sufficient for comfort and safety. First-aid kit is inspected and complete. There are three first aid kits available through out the facility. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed; first-aid training for staff is current. Staff training is current according to administrator. Anna is a certified RCFE administrator (x 5/2021) that oversees facility operations. According to her she submitted her renewal certificate. She says she provided all documents and training verification to the Administrator Certification Section (ACS) but has not received an update. LPA observed the documents she submitted to ACS including the payment checks and training hours. She says she will follow up again regarding this. Water temperature is tested at 105F on ground level bathroom. Bathrooms and shower rooms have grab bars and non-skid mats in showers. PPE is observed as in place in exterior storage building. Fire extinguishers are charged and ready for use last being inspected on 3/8/2022. Smoke alarms and carbon monoxide detectors are in place.

The following updated forms were received during today's inspection:

• LIC610E Emergency Disaster Plan
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report

There are no citations issued during today's inspection. Report is reviewed with administrator Anna Allas.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022
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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