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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202832
Report Date: 01/05/2026
Date Signed: 01/05/2026 03:08:47 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/05/2026 03:08 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:PENINSULA SENIOR LIVING MAGNOLIA LLCFACILITY NUMBER:
435202832
ADMINISTRATOR/
DIRECTOR:		VERMA, SUNILFACILITY TYPE:
740
ADDRESS:176 S BERNARDO AVETELEPHONE:
(408) 807-1984
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY: 30CENSUS: 18DATE:
01/05/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Neeru VermaTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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To complete annual visit of 12/8/25, LPA Jeung reviewed clients' medications and issued citations for Type B deficiencies observed on 12/8/25, which are cited as per California Code of REgulations, Title 22 on following pages.

LPA also reviewed corrections made as per Type A citations issued on 12/8/25. Deficiency is recited and citation appears on following page.
NAME OF LICENSING PROGRAM MANAGER: Cowan April
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 01/05/2026 03:08 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/05/2026 at 12:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/12/2026
Section Cited
CCR
87608(a)(3)

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POSTURAL SUPPORTS
A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
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MD orders for half bed rails for clients in rooms #2, #3, #7, #8, #9, #15, #17, #18, #19, #20 will be sent to CCLD BY DUE DATE
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This requirement is not met, as residents in rooms #2, #3, #7, #8, #9, #15, #17, #18, #19, #20 have half bed rails on beds, which poses a potential health, safety or personal rights risk to clients in care.
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Type B
01/12/2026
Section Cited
CCR87463(a)

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REAPPRAISALS
The pre-admission appraisal, as specified in Section 87457... shall be updated in writing as frequently as necessary or once every 12 months... to note significant changes in condition...and to keep the appraisal accurate.
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Written appraisals for clients #2, #7, #9 will be updated and sent to CCLD BY DUE DATE
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This requirement is not met, as appraisals for clients #2, #7, #9 are dated over 12 months ago. Licensee failed to ensure that written appraisals are updated annually, which poses a potential health safety or personal rights risk to clients 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.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/05/2026 03:08 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/05/2026 at 12:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/05/2026
Section Cited
CCR
87463(h)(1)

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REAPPRAISALS
The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every 12 months, either in person or by video appointment...documentation of the annual routine visit...shall be added to the resident's record.
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MD reports for clients #2 and #9 will be sent to CCLD BY DUE DATE
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This requirement is not met, as MD reports for clients #2 and #9 are dated more than 12 months ago. Licensee failed to ensure that MD reports are completed annually, which poses a potential health, safety or personal rights risk to clients in care.
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Type B
01/12/2026
Section Cited
CCR87507(a)(1)(A)

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ADMISSION AGREEMENTS
The licensee shall complete an individual written admission agreement...text of the admission agreement, including any attachments and modifications, shall be printed in black type of not less than 12-point type size, on plain white paper. The print
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Plan of correction to be sent to CCLD BY DUE DATE.
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shall appear on one side of the paper only.
This requirement is not met, as original signed admission agreement for client #9 is printed on both sides of paper, which poses a potential health, safety or personal rights risk to clients 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.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/05/2026 03:08 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/05/2026 at 01:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/12/2026
Section Cited
HSC
1569.695(f)(1)

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EMERGENCY PLANS
A facility shall have...the following in place: An evacuation chair at each stairwell, on or before July 1, 2019.
This requirement is not met, as there are no evacuation chairs in 3 stairwells.
Licensee failed to ensure that evacuation
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Evacuation chairs will be installed in each of 3 stairwells, and proof of correction to be sent to CCLD BY DUE DATE
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chairs are installed in each stairwell, which poses a potential health, safety or personal rights risk to clients in care.
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Type B
01/12/2026
Section Cited
CCR87411(c)(1)

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PERSONNEL REQUIREMENTS - GENERAL
Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met, as there is no evidence that staff #1 and #2 have
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Proof of current first aid training for staff #1 and #2 will be sent to CCLD BY DUE DATE
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current first-aid training, which poses a potential health, safety or personal rights risk to clients in care. Licensee failed to ensure that all caregivers have current first-aid training.
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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.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/05/2026 03:08 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/05/2026 at 01:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/05/2026
Section Cited
CCR
87412(a)(1-8,11)

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PERSONNEL RECORDS
The licensee shall ensure that personnel records are maintained on... each employee. Each personnel record shall contain...Employee's full name, Social Security number, Date of employment, Written verification that the employee is at least 18 years of age, including...a
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Job application and health screening for staff #1 sent to CCLD on 12/10/25.

Deficiency corrected and cleared
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copy of his/her birth certificate or driver's license, Home address and telephone number, Educational background, Past experience, including...former employers... position for which employed...health screening....
REcords for staff #1 do not include job application and health screening
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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.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


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Document Has Been Signed on 01/05/2026 03:08 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/05/2026 at 01:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/06/2026
Section Cited
CCR
87303(e)(2)

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MAINTENANCE AND OPERATION
Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F .
This requirement is not met, as hot water
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Hot water temperature will be lowered and maintained within range of 105 to 120 degrees F. Proof of correction to be submitted to CCLD BY DUE DATE
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temperature tested at 140 degrees in room 12 on 2nd floor. Licensee failed to ensure that hot water temperature is within range of 105 to 120 degrees F., which poses an immediate health and safety risk to clients in care. This deficiency was cited on 12/8/25, but not corrected.
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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.
Cowan April
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
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