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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202832
Report Date: 04/04/2024
Date Signed: 04/04/2024 09:36:43 AM


Document Has Been Signed on 04/04/2024 09:36 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: 17DATE:
04/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Co-Administrator, Maryann VizcondeTIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Simi Rai conducted a case management visit to follow up on deficiency cited during the case management visit conducted on 3/21/2024. LPA Rai met with Co-Administrator (CADM) Maryann Vizconde and stated the purpose of the visit.

On 3/21/2024, the Licensee was cited facility for R1 was not provided care and supervision to meet R1’s needs wherein R1 left the facility unassisted while facility staff were unaware.

On 3/21/2024, CADM, on behalf of Licensee, submitted Plan of Correction.

During visit, LPA reviewed and discussed the Plan of Correction with Co-Administrator, Maryann Vizconde. CADM stated the safety meetings are held on a every shift along with the endorsements from one shift to another. CADM has been leading the safety meetings. The follow deficiencies and plan of corrections were reviewed and cleared during the visit:

For regulation CCR 87468.1(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities, LPA Rai observed the safety meeting records which will be held every shift. Co-Administrator, Maryann Vizconde stated the facility will install delayed egress doors. LPA Rai advised to review CCR 87705 Care of Persons with Dementia to follow the initial and continuing requirements to be met for the licensee to utilize delayed egress devices on exterior doors or perimeter fence gates.

Based on today's inspection visit, the Administrator and staff have corrected all of the above citation/deficiencies. Plan of Correction (POC) clearance is issued and provided to Co-Administrator, Maryann Vizconde.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed Co-Administrator, Maryann Vizconde and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
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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