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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601096
Report Date: 12/08/2023
Date Signed: 12/08/2023 10:50:35 AM


Document Has Been Signed on 12/08/2023 10:50 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:PENINSULA ELDERLY CARE HOME - LAURELWOOD LLCFACILITY NUMBER:
415601096
ADMINISTRATOR:VERMA, NEERUFACILITY TYPE:
740
ADDRESS:324 LAUREL STREETTELEPHONE:
(408) 807-1984
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY:6CENSUS: 6DATE:
12/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Assistant Administrator, Jennifer TobiasTIME COMPLETED:
11:00 AM
NARRATIVE
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On December 8, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit to follow up on a total dependent care exception request from the facility for resident #1 (R1). LPA met with Assistant Administrator, Jennifer Tobias and explained the purpose of the visit.

During the visit, LPA observed R1, obtained training records, and interviewed the administrator. Based on observations, R1 was observed sitting on a chair in his/her bedroom. R1 is able to communicate very little, however according to assistant administrator, R1 is able to tell staff if he/she needs anything.

According to the assistant administrator and staff interviewed, R1 is two persons assist. Staff use a hoyer-lift to transfer R1. Staff interviewed indicated, R1 is able to hold utensils and glasses, however R1 can't bring it up to his/her mouth. Assistant administrator indicated that R1 is unable to conduct one ADL on his/her own and a staff will always have to assist. R1 is able to help staff repositioning himself/herself.

LPA requested copies of staff training for hoyer-lifts, however assistant administrator was unable to provide copies. According to the administrator, the facility provides training for postural support and staff are trained for hoyer-lifts, however there was no documentation provided to LPA to show staff are trained to use hoyer-lifts.

Deficient is cited under California Health and Safety Code on the LIC809D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with the Assistant Administrator and a copy is provided via email.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 12/08/2023 10:50 AM - 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: PENINSULA ELDERLY CARE HOME - LAURELWOOD LLC
FACILITY NUMBER: 415601096

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2023
Section Cited
CCR
87412(c)

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87412 Personnel Records:
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

Violation of this regulation is not met as evidenced by:
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Licensee/Administrator to conduct an in-service training with staff on how to properly operate a hoyer-lift by 12/15/2023.
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Staff use a hoyer-lift to transfer R1. Licensee failed to provide LPA staff training documentation to show staff are trained to use a hoyer-lift.
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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2