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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202832
Report Date: 02/07/2022
Date Signed: 02/07/2022 01:43:50 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: 19DATE:
02/07/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Neeru VermaTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) David Marrufo, Licensing Program Manager Sarah Yip, and Nurse Lori Kopplinger conducted a tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility and met with Administrator Neeru Verma.

Administrator Neery Verma reports that there are currently 4 COVID-19 positive residents and 1 COVID-19 positive staff.

During today's tele-visit, the following recommendations were made to the facility by Nurse Lori Kopplinger:

1. Place entire list of COVID symptoms on outside of entrance door.
2. Visitor logs should have visitor's first and last name and document temperatures.
3. Staff, not the visitor, should document visitor's temperature.
4. Post signs in bathrooms instructing to wash hands for 20 seconds at least.
5. Staff need to be fit tested for N95 masks.
6. Use disinfectants that have a contact time of 2 minutes or less.

No deficiencies were cited as per California Code of Regulations, Title 22.

This report was reviewed with with Lori Kopplinger. A copy of the report will be sent to her for to be signed and returned to CCL.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
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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