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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601096
Report Date: 02/07/2025
Date Signed: 02/07/2025 03:24:26 PM

Document Has Been Signed on 02/07/2025 03:24 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:
02/07/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:31 PM
MET WITH:Jennifer Tobias, Administrator and Arlene Jonson, CareviverTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 2/7/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to continue the Annual 1-year required inspection started on 1/9/2025. LPA Calandra was greeted by Jennifer Tobias, Administrator and explained the purpose of the visit.

All sharp objects, poisons, and detergents were observed to be locked and in-accessible to persons in care.

LPA reviewed 5 resident records and 5 staff files. All were observed to be complete.

A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records kept at the facility.

LPA Calandra received a copy of the Facility's Dementia Care Plan.

No deficiencies were cited during today's visit.

An exit interview was conducted. This report was reviewed with Jennifer Tobias, Administrator and a copy of the report left the facility.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2025
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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