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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600996
Report Date: 06/28/2021
Date Signed: 06/28/2021 06:02:21 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 HOMEFACILITY NUMBER:
415600996
ADMINISTRATOR:TOBIAS, JENNIFERFACILITY TYPE:
740
ADDRESS:108 DARCY AVETELEPHONE:
(650) 572-9208
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 5DATE:
06/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Jennifer TobiasTIME COMPLETED:
06:00 PM
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LPA Audrey Jeung toured facility and grounds, consisting of 6 client bedrooms and a staff bedroom for one staff. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. 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. Liquid soap is available at all sinks. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 6 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 (x 11/21) that oversees facility operations.

The following updated forms/information are requested to be submitted to CCLD BY 7/6/21:

• LIC 309 Administrative Organization
• Proof of current Liability Insurance
• LIC 808 Covid Mitigation Plan (updated with facility specific information)


Updated Emergency Disaster Plan (LIC610E) and Personnel Report (LIC500) are given to LPA today.


No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are cited.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
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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