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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202832
Report Date: 03/21/2024
Date Signed: 03/21/2024 11:09:59 AM


Document Has Been Signed on 03/21/2024 11:09 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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: 18DATE:
03/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Licensee, Neeru VermaTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit today. LPA Rai met with Licensee, Neeru Verma and stated purpose of today's visit.

The purpose of the case management visit was to follow up on an incident which occurred on 2/26/2024 at 4:45pm when resident (R1) left the facility unassisted. Per Incident Report, the facility received a phone call from R1's child stating R1 was found by the local law enforcement officers. The incident was reported to the Department via Unusual Incident Report on 2/28/2024.

LPA Rai interviewed 2 staff at the facility (LIC & S1). LIC stated the R1 is a Memory Care resident and is unable to leave the facility unassisted as stated in their LIC 602 Physician's Report dated 10/12/2023. LIC stated the resident left the facility from the front door, following after the LIC, wherein the alarm sensor did not capture resident leaving the facility.

S1 stated the facility staff were not aware of resident leaving the facility. Facilty staff conducted a routine safety check and it was assessed the resident was not present at the facility. S1 stated the resident left the facility in between the status checks conducted by staff. S1 stated the staff conducted 30 minute status checks on the resident due to the wandering behavior.

S1 stated the staff alerted LIC, resident's family and the local law enforcement agency. S1 stated the resident was found 0.2 miles away from the facility by the local law enforcement officer and resident's family member brought resident back to the facilty.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.
Exit interview was conducted with Licensee, Neeru Verma and a copy of this report was provided. Appeal Rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
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 03/21/2024 11:09 AM - 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: PENINSULA SENIOR LIVING MAGNOLIA LLC
FACILITY NUMBER: 435202832

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/22/2024
Section Cited
CCR
87468.1(a)(4)

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Additional Personal Rights of Residents in Privately Operated Facilities:(a)... residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in...qualifications, and competency to meet
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Licensee will submit a written plan of action to ensure resident's safety and provide in-service training by POC date. Licensee agreed and understood.
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their needs. This requirement was not met as evidenced by: R1 was not provided care and supervision to meet R1's needs wherein R1 left the facility unassisted while facility staff were unaware which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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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: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
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