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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601070
Report Date: 10/08/2025
Date Signed: 10/08/2025 11:46:16 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/06/2025 and conducted by Evaluator Komal Curley
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20251006120240
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: 106DATE:
10/08/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Katherine TazawaTIME COMPLETED:
11:57 PM
ALLEGATION(S):
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Staff did not ensure that resident was transported to religious services.
INVESTIGATION FINDINGS:
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On October 8, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced 10-day complaint inspection. LPA met with Administrator, Katherine Tazawa and explained the purpose of the visit.

Regarding the allegation, staff did not ensure that resident was transported to religious services, according to the reporting party, facility staff cancelled a schedule pick up for Resident 1 (R1) to attend religious services and the facility failed to notify R1 or R1's responsible party. In addition, the reporting party indicated that R1 had to spend $23 on Uber for transportation.

During the investigation, LPA interviewed staff and reviewed documents. Based on documents reviewed and staff interviewed, the facility paid for R1's Uber with the facility's funds. Based on interviewed staff, the facility never cancelled transportation for R1. R1's responsible party got upset due to Quickshop being scheduled on Saturday, the same day R1 goes to his/her religious services. According to staff interviewed, the facility did not receive any notice from R1 or R1's responsible party to transport R1 to his/her religious services. (continue to 9099C).
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 14-AS-20251006120240
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 REY
FACILITY NUMBER: 415601070
VISIT DATE: 10/08/2025
NARRATIVE
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Staff interviewed indicated that they were willing to accommodate R1 and have him/her go to church with a friend, who picks R1 up and goes with R1, then have the facility driver pick R1 up from church and take him/her to Quickshop, however R1's responsible party stated no because R1 will be tired after church. LPA reviewed transportation log for the week, however there was no documentation stating that R1 or R1's responsible party scheduled an outting to church. The facility ended up accommodating R1 by taking R1 to Quickshop on Friday so that R1 can go to church on Saturday.

Based on interviews conducted and information collected, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED.

Report is reviewed with administrator, Katherine Tazawa and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2