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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600976
Report Date: 02/15/2024
Date Signed: 02/15/2024 03:53:01 PM


Document Has Been Signed on 02/15/2024 03:53 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:ANNA ALLASFACILITY TYPE:
740
ADDRESS:205 COLLINS AVETELEPHONE:
(650) 731-4670
CITY:COLMASTATE: CAZIP CODE:
94014
CAPACITY:57CENSUS: 45DATE:
02/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator - Anna AllasTIME COMPLETED:
04:00 PM
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On 02/15/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - incident visit regarding a police visit to the facility made on this day in the morning hours. LPA met with administrator Anna Allas and explained the purpose of today's visit.

During complaint visit made on this day regarding complaint #14-AS-20240214151800. LPA was informed by Anna that the police department came to the facility in the morning hours today regarding medications that R1 supposedly had and where it came from and also the room door of R1 being locked. Staff demonstrated to the officer how the room is unlockable from the outside and how they unlock it. Responding officer provided the facility with a police report number regarding the visit. Police took no further actions during the visit. Facility will provide an incident regarding the police visit. F

No citations issued. Report reviewed with Anna.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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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