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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320398
Report Date: 01/29/2024
Date Signed: 01/29/2024 12:08:20 PM

Document Has Been Signed on 01/29/2024 12:08 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:PENINSULA POINTE BY COGIRFACILITY NUMBER:
198320398
ADMINISTRATOR:KITAGAWA, DESIREEFACILITY TYPE:
740
ADDRESS:27520 HAWTHORNE BOULEVARDTELEPHONE:
(310) 697-6236
CITY:ROLLING HILLS ESTATESTATE: CAZIP CODE:
90274
CAPACITY: 121CENSUS: 0DATE:
01/29/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Desiree Kitagawa, Administrator
Benoit Levesque, Applicant		TIME COMPLETED:
12:05 PM
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Component II completion: Successful

Facility Type: Initial
Application Type: Residential Care Facility for Elderly (RCFE)
Capacity:
Census (if any clients in care): none
COMP II Participants: Desiree Kitagawa, Administrator
Benoit Levesque, Applicant
Interview Method: Telephone interview

On January 29, 2024 at 11:00 AM, applicant and administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant and Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing Requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Applicant and Administrator. Copy of report sent via email and request to return sign copy by end of business day today to CAB.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
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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