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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601096
Report Date: 01/09/2025
Date Signed: 01/09/2025 04:40:02 PM

Document Has Been Signed on 01/09/2025 04:40 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 ELDERLY CARE HOME - LAURELWOOD LLCFACILITY NUMBER:
415601096
ADMINISTRATOR/
DIRECTOR:		VERMA, NEERUFACILITY TYPE:
740
ADDRESS:324 LAUREL STREETTELEPHONE:
(408) 807-1984
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY: 6CENSUS: 6DATE:
01/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:31 PM
MET WITH:Jennifer Tobias, Administrator and Arlene Jonson, CareviverTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On 1/9/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 2:31 PM to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Arlene Jonson, Caregiver and explained the purpose of the visit.

LPA toured the physical plant. This is a 1-story building with 6 bedrooms (5 bedrooms for residents and 1 for staff, 7 bathrooms, a dining room, living room, kitchen, and backyard. Hot water temperature was measured within the required 105-120 degrees Fahrenheit. All bedrooms had the required furniture and sufficient lighting. The facility was maintained at a comfortable temperature. The facility had the required 7 days of non perishables and 2 days of perishables on hand. No food was expired.

The Annual will be completed at a later date.

Deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties.

An exit interview was conducted. This report was reviewed with Jennifer Tobias, Administrator and a copy of the report along with Appeal rights left at the facility.


SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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 01/09/2025 04:40 PM - It Cannot Be Edited


Created By: John Calandra On 01/09/2025 at 03:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(d)
87355(d): Criminal Record Clearance: All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.

This requirement is not as met as evidenced by:



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview of Administrator and document review, S1, a private companion employed by a private caregiving agency does not have criminal record clearance(in pending status), which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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Licensee/Administrator to contact Agency and ensure S1 is fingerprint cleared prior to S1 working in the facility. Licensee/Administrator to send proof of fingerprint clearance to the Department.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
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