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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600593
Report Date: 11/10/2021
Date Signed: 11/10/2021 01:28:44 PM

Document Has Been Signed on 11/10/2021 01:28 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PENINSULA VILLAGEFACILITY NUMBER:
415600593
ADMINISTRATOR:RAMOS, ANDREWFACILITY TYPE:
740
ADDRESS:108 E. HILLSDALE BLVD.TELEPHONE:
(650) 345-1357
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 3DATE:
11/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Terry IllastronTIME COMPLETED:
01:30 PM
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LPA Audrey Jeung toured facility and grounds of this 1-level home, consisting of 6 client bedrooms and a staff bedroom--each with a private half bathroom--and a shower room, kitchen, living, and dining rooms. There is an enclosed patio and backyard. There is a 1 car garage, where washer and dryer are located. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 3 residents present, and 3 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Terry Illastron is a certified RCFE administrator (x 12/21) that oversees facility operations.

The following updated forms/information are requested to be submitted to CCLD BY 11/24/21:

• LIC 308 Designation of Administrative Responsibility
• Current lease agreement
• Current liability insurance
• LIC 999 Facility Sketch (including room dimensions)
• LIC 500 Personnel Report
• LIC 309 Administrative Organization
• LIC 610 Emergency Disaster Plan

Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page. See Technical Advisory Notes for additional information.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2021
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 11/10/2021 01:28 PM - It Cannot Be Edited


Created By: Audrey Jeung On 11/10/2021 at 12:55 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PENINSULA VILLAGE
FACILITY NUMBER: 415600593

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
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 evidenced by:
Deficient Practice Statement
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Based on confirmation from administrator, the licensee did not comply with the section cited above, as 6 out of 6 staff have expired first-aid training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/24/2021
Plan of Correction
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Proof of current first-aid training for 6 staff will be sent to CCLD by DUE DATE
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Julio Montes
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2021


LIC809 (FAS) - (06/04)
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