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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600996
Report Date: 02/05/2021
Date Signed: 02/05/2021 04:43:16 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/22/2019 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20190822132431
FACILITY NAME:PENINSULA ELDERLY CARE HOMEFACILITY NUMBER:
415600996
ADMINISTRATOR:TOBIAS, JENNIFERFACILITY TYPE:
740
ADDRESS:108 DARCY AVETELEPHONE:
(650) 572-9208
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 5DATE:
02/05/2021
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Neeru VermaTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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-- Facility staff speak inappropriately to residents
INVESTIGATION FINDINGS:
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Based on LPA Jeung's investigation--which included review of clients' records and interviews with clients and staff--the preponderance of evidence standard has been met. Therefore, the above allegation is determined to be SUBSTANTIATED.

Deficiency of the California Code of Regulations, Title 22, is cited on a following page.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 14-AS-20190822132431
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PENINSULA ELDERLY CARE HOME
FACILITY NUMBER: 415600996
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/19/2021
Section Cited
CCR
87468.1(a)(1)
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PERSONAL RIGHTS OF ALL RESIDENTS
Residents in all residential care facilities for the elderly shall have the personal right...
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met, as evidenced by information obtained from interviews with clients and/or their responsible
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Plan of correction to be submitted to CCLD BY DUE DATE, which shall include remedial training--clients' rights and other--to be given to caregivers.
Licensee to closely monitor staff interactions with clients on an ongoing basis to ensure that residents are at all times treated with dignity and respect.
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parties. Licensee failed to ensure that staff are at all times respectful, courteous, patient and responsive to the needs of all residents, which poses an immediate health, safety or personal rights risk to clients in care. Staff were described as being rude to and impatient with residents, and unresponsive to their needs. This was confirmed by clients.
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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.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2