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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601034
Report Date: 11/08/2024
Date Signed: 11/08/2024 10:07:54 AM

Document Has Been Signed on 11/08/2024 10:07 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: 7DATE:
11/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Evelyn Tabago, Caretaker and Jennifer Tobias, AdministratorTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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On November 6, 2024, Licensing Program Analyst (LPA) John Calandra arrived at the facility at 8:30 AM to conducted an unannounced follow up Case Management visit. Purpose of visit is due to a self reported incident that was reported on 10/26/2024. LPA Calandra was greeted by Evelyn Tabago, Caretaker and explained the purpose of the visit. Jennifer Tobias, Administrator arrived later during the visit.

On October 26, 2024, the Department received a report from the facility stating that R1 had slapped and spit on S1.

Per interview with the Administrator, Jennifer Tobias, R1 went to see R1's Neurologist recently and new medications have been prescribed but not started yet.

During the visit, LPA reviewed R1's LIC 602 and Care Plan and obtained electronic copies of both documents.

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: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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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