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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601034
Report Date: 11/01/2022
Date Signed: 11/01/2022 02:39:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/09/2020 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20201109115234
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:
11/01/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Caregiver, Evelyn TabagoTIME COMPLETED:
02:47 PM
ALLEGATION(S):
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Facility failed to administer medication properly
Staff did not ensure facility was free from pests
INVESTIGATION FINDINGS:
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On November 1, 2022, Licensing Program Analyst (LPA) conducted an unannounced complaint visit to deliver findings for the above allegations. LPA met with Caregiver, Evelyn Tabago and explained the purpose of the visit. In addition, LPA spoke to Administrator, Jennifer Tobias via telephone and explained the purpose of the visit.

Regarding the allegation that facility failed to administer medication properly, according to the reporting party, Resident #1 (R1’s) medications were found on the floor or in R1’s laundry. During the investigation, Administrator indicated that R1 was unable to manage his/her own medication. LPA interviewed staff and it was acknowledged by the Licensee that medication was found on the floor. In addition, interviewed staff admitted that the caregivers made a mistake and that staff received training immediately after medications were found on the floor.

Regarding the allegation that staff did not ensure facility was free from pests, according to the reporting party, ants were observed crawling on the facility plates. During the investigation, LPA interviewed the Licensee and it was acknowledged that the facility did have an issue with ants. Although the facility called pest control and took care of the ant issue, the facility did have pests.

Based on the information collected and interviews conducted the above allegations are SUBSTANTIATED. The preponderance of evidence standard has been met, therefore the above allegations is determined to be Substantiated.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 9099D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with the Caregiver, and a copy is provided with appeals rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 14-AS-20201109115234
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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-LAUREL LLC
FACILITY NUMBER: 415601034
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2022
Section Cited
CCR
87465(c)
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Incidential Medical and Dental Care: (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met...

Violation of this regulation is evidenced by:
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Licensee conducted an in-service training after this incident occurred. Deficiency was cleared and a copy of the in-service training was provided.
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Based on interviews condcuted and information collected, R1 was unable to manage his/her own medication so facility staff would ensure medication was being taken, however it was acknowledged that S1's medication was found on the floor. In addition, interviewed staff admitted that the caregivers made a mistake.
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Type B
11/08/2022
Section Cited
CCR
87303(a)
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Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times...

Violation of this regulation is evidenced by:
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The facility contacted pest control and took care of the issue. Deficiency was cleared-- Licensee provided previous LPA with copy of the pest control receipt.
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Based on interviews conducted and information collected, it was acknowledged by staff that the facility did have an ant problem.
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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: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/09/2020 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20201109115234

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:
11/01/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Caregiver, Evelyn TabagoTIME COMPLETED:
02:47 PM
ALLEGATION(S):
1
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3
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5
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9
Facility fails to provide fresh and balance meals to residents
Staff do not provide activities for residents in care
Staff make residents stay in their rooms
INVESTIGATION FINDINGS:
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On November 1, 2022, Licensing Program Analyst (LPA) conducted an unannounced complaint visit to deliver findings for the above allegations. LPA met with Caregiver, Evelyn Tabago and explained the purpose of the visit. In addition, LPA spoke to Administrator, Jennifer Tobias via telephone and explained the purpose of the visit.

Regarding the allegation that the facility failed to provide fresh and balanced meals to residents, according to the reporting party, the facility does not provide residents good quality food and serves residents the same meals all the time. During the investigation, LPA interviewed staff and it was indicated that each resident gets served 3 meals a day based on their diets. According to the Licensee, although the facility buys store bought food, the facility ensures that residents are provided with nutritious meals that meet the residents’ diets.

Regarding the allegation that staff do not provide activities for residents in care, according to the reporting party, staff do not provide activities for residents. According to the staff interviewed, due to COVID-19, the facility was unable to allow visitors to come in and have group activities, however the facility did ensure there were indoor activities residents could participate in; playing bingo and cards, Youtube exercise, and having sing alongs.

CONT. to 9099C

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 14-AS-20201109115234
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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-LAUREL LLC
FACILITY NUMBER: 415601034
VISIT DATE: 11/01/2022
NARRATIVE
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Regarding the allegation that staff make residents stay in their rooms, according to the reporting party, after the residents have lunch, the staff make residents go back to their rooms and take a nap. During the investigation, it was found that although the facility was going through a COVID outbreak during the time this complaint was filed, the facility staff allowed residents to come out of their rooms and sit in the common area and ensured residents were maintaining social distancing.

Based on the interviews conducted and information collected, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.

Report is reviewed with Caregiver and a copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4