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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601034
Report Date: 11/06/2024
Date Signed: 11/06/2024 11:51:02 AM

Document Has Been Signed on 11/06/2024 11:51 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: 12TOTAL ENROLLED CHILDREN: 0CENSUS: 7DATE:
11/06/2024
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Jennifer Tobias, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On November 6, 2024, Licensing Program Analyst (LPA) John Calandra arrived at the facility at 8:40 AM to conducted an unannounced Case Management visit. Purpose of visit is due to a self reported incident that was reported on 10/26/2024. LPA met with Administrator, Jennifer Tobias and explained the purpose of the visit. Neeru Verma, Head of Operations arrived later during the visit.

The incident occurring on 10/26/2024, involved a resident (R1) striking and spitting on a staff member, S1. The incident was reported to CCLD and confirmed based on the incident report and interview with Administrator, Jennifer Tobias.

During the visit, LPA Calandra interviewed 4 residents, staff, and Administrator.

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.
Andrea MedlinTELEPHONE: (650) 266-8811
John CalandraTELEPHONE: 650-266-8800
DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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