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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601034
Report Date: 07/23/2021
Date Signed: 07/23/2021 04:13:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PENINSULA ELDERLY CARE HOME-LAUREL LLCFACILITY NUMBER:
415601034
ADMINISTRATOR:TOBIAS, JENNIFERFACILITY TYPE:
740
ADDRESS:1064 LAUREL STREETTELEPHONE:
(408) 807-1984
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY:12CENSUS: 5DATE:
07/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Jennifer TobiasTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Gladys Kuizon conducted an annual inspection today and met with Administrator Jennifer Tobias.

At 1:05 PM, LPA entered the facility through the facility's central entry point and was screened by staff. At 1:10 PM, a tour of the facility was conducted. COVID-19 postings were observed. Staff were observed wearing face coverings. 5 residents and 2 staff were present during inspection.

The facility has at least 30 days' supply of personal protective equipment (PPE) including. Hand sanitizers, soap, and paper supplies were observed available. Hand-washing guides were posted by hand-washing stations. At least 2 days' supply of perishable foods and at least 1 week's supply of non-perishable foods are available in the premises.

Storage sheds were inspected in the backyard. Exit routes were observed clear and unobstructed. No bodies of water were observed.

According to Administrator, the facility has achieved 100% vaccination rate against COVID-19 for both residents and staff. The facility is currently accepting visitors inside the facility.

The facility's mitigation plan was received and reviewed by Community Care Licensing.

No deficiencies were cited. Exit interview conducted with Administrator and a copy of this report was provided during visit.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
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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