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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600996
Report Date: 06/18/2024
Date Signed: 06/18/2024 05:47:58 PM


Document Has Been Signed on 06/18/2024 05:47 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 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:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Jennifer TobiasTIME COMPLETED:
05:45 PM
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LPA Audrey Jeung toured facility and grounds, consisting of 6 client bedrooms and a staff bedroom for one staff. Four client rooms have private half bathrooms and one bedroom is adjacent to full bath/shower room. All client rooms have direct exiting to wrap around wooden deck. There is a living/dining room area and kitchen, as well as attached garage, where washer and dryer are located. No accessible bodies of water or fire safety hazards observed. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Hot water temperature tested at 105 degrees in bath/shower room. Liquid soap is available at all sinks. First-aid kit is inspected. A Disaster and Mass Casualty Plan is posted. There are 5 residents present, and 2 staff, plus the administrator. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Jennifer Tobias is a certified RCFE administrator that oversees facility operations. Some staff records are reviewed.

The following updated forms/information are requested to be submitted to CCLD BY 7/2/24:

• LIC 309 Administrative Organization
• Proof of current Liability Insurance
• LIC 500 Personnel Report

Client records will be reviewed at a later date, in addition to additional staff records.


No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are cited.
See Technical Advisory Note for additional information.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
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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