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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601034
Report Date: 07/11/2022
Date Signed: 07/11/2022 10:44:14 AM


Document Has Been Signed on 07/11/2022 10:44 AM - It Cannot Be Edited

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 HOME-LAUREL LLCFACILITY NUMBER:
415601034
ADMINISTRATOR:TOBIAS, JENNIFERFACILITY TYPE:
740
ADDRESS:1064 LAUREL STREETTELEPHONE:
(650) 264-8350
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY:12CENSUS: 7DATE:
07/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Caregiver, Evelyn TabagoTIME COMPLETED:
10:50 AM
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On June 11, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. LPA met with Caregiver, Evelyn Tabago, and Administrator, Jennifer Tobias joined shortly thereafter. LPA explained the purpose of the visit. Upon arrival, LPA observed the COVID-19 posting on the front door, however advised Caregiver to post more COVID reminder signage. LPA was screened at entry point and caregiver was able to provide LPA with screening log documentation for staff, residents, and visitors.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story facility with 7 bedrooms; all private rooms and 5 bathrooms; 2 full and 3 half baths. Infection control practices are present: entry procedures, face coverings, daily monitoring for residents and staff, COVID-19 signage posted throughout the facility, and 30-day PPE supply.

LPA observed bathrooms to be equipped with hand-washing signs, liquid soap, and paper towels. LPA advised caregiver to ensure communal bathrooms have a trash can with a fitted lid and the remove hand/bath towels from the bathrooms. LPA observed medications and toxins locked and inaccessible to residents. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable present. LPA observed sharps drawer to be unlocked and accessible to residents, however according to the administrator, the kitchen door is locked at all times unless staff is in the kitchen.

A comfortable temperature is maintained and lighting is sufficient for comfort. Extra linen was observed to be present. Washer and dryer was observed to be in good working condition. (CONT. TO 809C)
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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-LAUREL LLC
FACILITY NUMBER: 415601034
VISIT DATE: 07/11/2022
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LPA requested for the following to be submitted to CCLD by 7/18/2022:
  • LIC309 Administrative Organization
  • LIC308 Administrative Responsibility
  • LIC500 Personnel Report
  • LIC610E Emergency Disaster Plan
  • Administrator Certificate

This report is reviewed and discussed with Administrator, Jennifer Tobias; a copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
LIC809 (FAS) - (06/04)
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