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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601034
Report Date: 07/18/2024
Date Signed: 07/18/2024 11:47:48 AM

Document Has Been Signed on 07/18/2024 11:47 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PENINSULA ELDERLY CARE HOME-LAUREL LLCFACILITY NUMBER:
415601034
ADMINISTRATOR/
DIRECTOR:		TOBIAS, JENNIFERFACILITY TYPE:
740
ADDRESS:1064 LAUREL STREETTELEPHONE:
(650) 264-8350
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY: 12CENSUS: 6DATE:
07/18/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:39 AM
MET WITH:Jennifer Tobias, Adminsitrator and Alma Tamonte, CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On July 18, 2024, Licensing Program Analysts(LPAs) John Calandra and Yi "Sam" Jian, arrived at the facility at 8:39 AM to complete the annual 1-year required unnanounced Annual Inspection. LPAs Calandra and Jian were greeted by Alma Tamonte, Caregiver and explained the purpose of their visit. Administrator, Jennifer Tobias arrived later during the visit.

LPAs Calandra and Jian reviewed 4 staff files. All were observed to be complete.

LPAs Calandra and Jian interviewed 2 residents and 3 staff.

A Technical Violation was provided for not having a internet accessing device present that allows a resident to access it for discussion of personal or confidential information with a reasonable level of personal privacy.

No deficiencies were cited during today's visit.

An exit interview was conducted. This report was reviewed with Jennifer Tobias, Administrator and a copy of the report left at the facility.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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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