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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601034
Report Date: 06/19/2024
Date Signed: 06/19/2024 04:38:11 PM


Document Has Been Signed on 06/19/2024 04:38 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 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:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:56 PM
MET WITH:Evelyn Tabajo, Caregiver and Jennifer Tobias, Adminsitrator TIME COMPLETED:
04:45 PM
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On June 19, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 1:56 PM, to complete the Annual 1-year required inspection. LPA Calandra was greeted by Evelyn Tabajo, Caregiver and explained the purpose of the visit. Administrator, Jennifer Tobias arrived later during the visit.

LPA Calandra toured the physical plant. This is a 1-story building with 7 bedrooms, 5 bathrooms, a front yard and backyard, living room, dining room, kitchen, 2 storage spaces, and staff quarters in the garage. The facility's Fire Extinguisher was observed to be fully charged and last inspected on April 4, 2024. The facility's Fire Alarms and Carbon Monoxide detectors were observed to be in working order. All bedrooms had the required furniture and sufficient lighting. There were no accessible bodies of water or hazards observed. The facility's First Aid had the required items. Hot water temperature was measured within the required 105-120 degrees Fahrenheit. The facility was maintained at a comfortable temperature of 75 degrees Fahrenheit. The facility had the required 7 days of non perishables and 2 days of perishables on site. No food was expired.

LPA Calandra reviewed 5 resident files. All were observed to be complete.

All Sharp objects, disinfectants, and cleaning supplies were observed to be locked and in-accessible to persons in care.

LPA Calandra also reviewed Centrally Stored Medication Records. A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility.

No deficiencies were cited during today's visit.

The Annual will be completed on a later date.

An exit interview was conducted. This report was reviewed with Jennifer Tobias, Administrator and a copy of the report left at the facility.




SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
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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