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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601070
Report Date: 09/22/2023
Date Signed: 09/22/2023 04:51:01 PM


Document Has Been Signed on 09/22/2023 04:51 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 DEL REYFACILITY NUMBER:
415601070
ADMINISTRATOR:TAZAWA, KATHERINEFACILITY TYPE:
740
ADDRESS:165 PIERCE STREETTELEPHONE:
(650) 992-2100
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:150CENSUS: 105DATE:
09/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Joseph Bautista NallasTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 9/22/23 at 12:30PM. The Administrator Certificate was observed for Katherine Tazawa which expired 1/9/23. However, the certificate renewal documents and payment has been submitted to Community Care Licensing (CCL) and the documents were observed by LPA during this visit.

LPA met with Joseph Bautista Nallas, Business Manager and Mariana Pelayo, Regional Nurse and Edgardo Baclaan, Environmental Services Director and stated the purpose of todays visit. The facility is licensed for a capacity of 150 residents of which 20 maybe bedridden on the first floor only and the 140 non-ambulatory on the first and second floors. Hospice for 20 approved. At this time there are 0 bedridden and 5 residents receiving hospice care services. Infection Control Plan submitted to CCL. LPA observed oxygen signs posted.
LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed and conversed with residents during this visit. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 70*F which is within the required range of 68-85*F. The hot water temperature was measured at 111.6*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed 3 staff and 3 resident files during this visit.
Upon a file review the following items were discussed to be submitted with any changes annually:
Any addendums to Infection Control Plan, Designation of Facility Responsibility (LIC308), Liability Insurance
Personnel Report (LIC500), Administrator Certificate-Updated
Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given
SUPERVISOR'S NAME: Victoria BrownTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
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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