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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601070
Report Date: 04/12/2022
Date Signed: 04/12/2022 05:57:25 PM


Document Has Been Signed on 04/12/2022 05:57 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:PENINSULA DEL REYFACILITY NUMBER:
415601070
ADMINISTRATOR:CAGULADA, DILLONFACILITY TYPE:
740
ADDRESS:165 PIERCE STREETTELEPHONE:
(650) 992-2100
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:150CENSUS: 72DATE:
04/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:55 PM
MET WITH:Katherine TazawaTIME COMPLETED:
06:00 PM
NARRATIVE
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After receipt of Incident Reports submitted to CCLD that there were residents with COVID infection in January 2022, it was subsequently disclosed to CCLD that at least 12 staff had COVID infection. However, this was not reported to CCLD in a timely manner. Upon receipt of reports of clients with COVID infection, LPA Jeung called facility and spoke with administrator Kevin Hogan on 1/14/22. During the conversation, he advised that facility was experiencing a "major staffing issue." As per information provided, 3 staff were diagnosed with COvId on 1/3/22. Facility failed to report staff with COVID infection by phone or written report until 1/14/22 when LPA initiated call for information about clients with COVID.

In addition, CCLD learned from San Mateo County Dept. of Public Health that a staff person was COVID positive through contact tracing in July 2021. Facility was aware that staff #1 was COVID positive, but failed to report this to CCLD, nor SMCDPH. Clients were not tested, according to administrator, despite recommendation by SMCDPH to test all clients.

Deficiency of the CA Code of Regulations, Title 22 is cited on a following page.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
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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Document Has Been Signed on 04/12/2022 05:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: PENINSULA DEL REY
FACILITY NUMBER: 415601070

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2022
Section Cited

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REPORTING REQUIRENotes:///882582B5004E0AE8/StartUp?OpenFrameset

San Bruno ASC-14MENTS
Licensee shall furnish to CCLD reports, including written report within 7 days of the occurrence of an epidemic outbreak, which threatens the welfare, safety or health of residents, personnel or visitors. Report shall be made within 24 hours either by telephone or fax to CCLD & to the local health officer when appropriate.
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Report shall include the resident's name, age, sex, date of admission... This requirement was not met, as 12 staff with Covid were not reported to CCLD until LPA called administrator in January 2022, & CCLD was not notified of COVID staff in July 2021, which posed a potential health & safety risk.
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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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022
LIC809 (FAS) - (06/04)
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