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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202832
Report Date: 11/22/2021
Date Signed: 11/22/2021 02:40:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PENINSULA SENIOR LIVING MAGNOLIA LLCFACILITY NUMBER:
435202832
ADMINISTRATOR:VERMA, SUNILFACILITY TYPE:
740
ADDRESS:176 S BERNARDO AVETELEPHONE:
(408) 807-1984
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY:30CENSUS: 15DATE:
11/22/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sunil Verma and Neeru VermaTIME COMPLETED:
02:45 PM
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Licensing Program Analysts (LPAs) Christine Dolores and Marybeth Donovan arrived unannounced to conduct a pre-licensing visit. LPAs met with Sunil Verma Administrator and Neeru Verma Designee Administrator.

There is currently residents living at the facility. The facility has two floors and has an approved fire clearance for 15 non-ambulatory, 15 bedridden, and hospice waiver for 10 hospice residents.

LPAs toured the facility inside and outside to include hallways, resident rooms, bathrooms, shower rooms, salon, activity room, living area, kitchen, dining room, patio, and laundry rooms. Elevator is in working condition. Resident apartments were equipped with proper furniture and lighting. Bedding and linens are available to the residents and observed clean. Bathrooms are equipped with grab bars, hygiene supplies, and toiletry. First floor hot water temperature was maintained at 107.3 degrees Fahrenheit. Second floor hot water temperature was maintained at 112.0 degrees Fahrenheit.

Facility is equipped with smoke detectors, carbon monoxide detectors, and fire extinguishers. Hallway and exit routes were observed free of obstruction.

LPAs observed the following posters: Personal Rights, If You See Something Say Something, Family Councils, and Resident Right to Counsel posted. Resident Admission Agreement and Theft and Loss policy is available for the public to review upon request.

LPAs reviewed 4 resident files and 4 staff files. Facility staff are fingerprint cleared. Resident files all contain the current documents.

Continue on LIC809-C.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: PENINSULA SENIOR LIVING MAGNOLIA LLC
FACILITY NUMBER: 435202832
VISIT DATE: 11/22/2021
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LPAs observed a Thanksgiving feast to include a fruits, yams, dessert, turkey, salad, and cheese tray. Refrigerator temperature was maintained at 35 degrees Fahrenheit. Freezer temperature was maintained at 0 degrees Fahrenheit.

LPAs conducted Component III with Sunil Verma Administrator and Neeru Verma Designee Administrator.

No issues noted during this pre-licensing inspection.

LPAs observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

This report was reviewed with Sunil Verma Administrator and Neeru Verma Designee Administrator and a copy of this report provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2