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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600996
Report Date: 11/29/2023
Date Signed: 11/29/2023 05:06:44 PM


Document Has Been Signed on 11/29/2023 05:06 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 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: 6DATE:
11/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Teresa Fernandez and Jennifer TobiasTIME COMPLETED:
05:15 PM
NARRATIVE
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In response to incident of 11/20/23 reported to CCLD on 11/22/23, LPA Jeung met with administrator, toured facility, reviewed client and staff records, and interviewed resident. At this time, further information is needed to adequately review incident.

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

Ms. Tobias is advised that annual licensing fee and late fee of $742 is overdue.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023
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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Document Has Been Signed on 11/29/2023 05:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 ELDERLY CARE HOME
FACILITY NUMBER: 415600996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/29/2023
Section Cited
CCR
87307(d)(6)

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PERSONAL ACCOMMODATIONS AND SERVICES
All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement was not met, as upholstered chair is observed blocking exit door in room 5, which exits to ramp in side
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Chair was relocated and does not block exit door in LPA's presence.
Deficiency corrected and cleared.
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yard. Licensee failed to ensure that indoor passageways are free of obstruction, which posed an immediate health and safety risk to clients in care.
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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023
LIC809 (FAS) - (06/04)
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