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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601070
Report Date: 04/12/2024
Date Signed: 04/12/2024 11:49:59 AM


Document Has Been Signed on 04/12/2024 11:49 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 DEL REYFACILITY NUMBER:
415601070
ADMINISTRATOR:TAZAWA, KATHERINEFACILITY TYPE:
740
ADDRESS:165 PIERCE STREETTELEPHONE:
(650) 992-2100
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:150CENSUS: 95DATE:
04/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Katherine TazawaTIME COMPLETED:
12:00 PM
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On 04/12/2024 Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year annual inspection visit. LPA met with executive director Katherine Tazawa.

LPA toured the facility with the executive director. The facility is licensed for a capacity of 150 residents of which 20 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 5 bedridden due to hospice. Infection Control Plan submitted to CCL. LPA observed oxygen signs posted on resident rooms where oxygen is in use.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed residents during this visit. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 70F which is within the required range of 68-85F. The hot water temperature was measured at 111.6F which is within the required range. 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 resident rooms at random and the rooms contained the required furniture outlined per regulations. Commercial laundry service was done in the facility laundry room and resident laundry machines as well in each resident room. LPA observed 3 staff and 3 resident files during this visit.

Facility files, including staff files and resident files, are to be reviewed on a later date. Katherine informed LPA that her administrator indicated that her administrator certificate is expired as of January 09, 2023 but did submit the required renewal documents and credits to the appropriate department for renewal and is currently pending and is awaiting a new certificate to be sent.

Report is reviewed with Katherine. No citations issued.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024
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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