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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601096
Report Date: 02/20/2024
Date Signed: 02/20/2024 02:47:02 PM


Document Has Been Signed on 02/20/2024 02:47 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
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:
02/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Assistant Administrator, Jennifer Tobias, TIME COMPLETED:
03:00 PM
NARRATIVE
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On February 20, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Assistant Administrator, Jennifer Tobias and explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No accessible bodies of water of fire safety hazards observed. LPA observed six private resident rooms, all of which have half-baths. Rooms were observed clean, in good repair with all required furniture. Half-baths observed were clean and odor-free. LPA observed two full bathrooms; equipped with liquid soap, paper towels, and non-skid mats. Extra linen and first aid kit was present.

Living room and dining room was toured, no tripping hazards were observed. A comfortable temperature is maintained and lighting is sufficient for comfort. LPA toured kitchen and observed two day perishable and seven day non-perishables. According to the Assistant Administrator, the water heater stopped working at 10:30am this morning and the facility currently does not have any hot water. During the visit, LPA observed third-party contractor working on repairing the water heater. Heating and A/C unit was observed working. Licensee faxed CCL an incident report immediately.

Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of November 2023. Emergency drills are logged and done every three months. Extra linen and first aid kit was observed present. Toxins, sharps, and medication were locked and inaccessible to residents in care.

LPA reviewed 5 resident records and 5 staff records. Staff records are complete, with training logs that have met the basic requirement. 2/5 resident files reviewed did not have did not have pre-admission appraisals in resident file. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in additional civil penalties. Report is reviewed with Assistant administrator and a copy is provided with appeal rights.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
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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Document Has Been Signed on 02/20/2024 02:47 PM - 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: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on resident records reviewed, 2/5 of the resident records did not have pre-admission appraisals in the file
POC Due Date: 02/27/2024
Plan of Correction
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Licensee/Administrator shall submit a written plan to CCL on how the facility will ensure compliance with CCR 87465. This includes ensuring all required resident documentation is maintained in resident files.
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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
LIC809 (FAS) - (06/04)
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