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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601070
Report Date: 04/16/2026
Date Signed: 04/16/2026 02:46:29 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/09/2026 and conducted by Evaluator Komal Curley
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20260409081451
FACILITY NAME:PENINSULA DEL REYFACILITY NUMBER:
415601070
ADMINISTRATOR:TAZAWA, KATHERINEFACILITY TYPE:
740
ADDRESS:165 PIERCE STREETTELEPHONE:
(650) 992-2100
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:150CENSUS: 113DATE:
04/16/2026
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator, Katherine Tazawa TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not install resident's grab bar
INVESTIGATION FINDINGS:
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On April 16, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced 10-day complaint visit. LPA met with Administrator, Katherine Tazawa and explained the purpose of the visit.

Regarding the allegation, staff did not install resident's grab bar, according to the reporting party, on 4/1/26, maintenance director notified Resident 1's (R1’s) responsible party that a grab bar will be installed by R1’s entrance door by 4/2 for reasonable accommodations, however on 4/2 the maintenance director notified R1’s responsible party that he did not have the grab bar available and had to order one. As of 4/7/26, the grab bar has still not been installed in R1’s room.

During the visit, LPA reviewed documents, interviewed the administrator, reviewed service order, and observed R1's room. Based on observations, LPA observed the grab bar installed in R1's room by the entrance door. According to the administrator and documents reviewed, on 3/31/26, R1's responsible party emailed Administrator and Director of Assisted Living requesting a grab bar/hand rail to be installed In R1's room on 4/3/26. (Continue to 9099C).
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 14-AS-20260409081451
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PENINSULA DEL REY
FACILITY NUMBER: 415601070
VISIT DATE: 04/16/2026
NARRATIVE
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According to the administrator, on the same day, she notified the Maintenance Director and Director of Assisted Living to survey the area for the grab bars and to ensure it does not interfere with opening and closing of the fire door. The administrator indicated, she emailed R1's responsible party on 4/3/26, notifying him/her that the Maintenance Director needed to assess the area and check to see if they had the grab bar on hand and notified R1's responsible party that the grab bar was ordered on 4/2/26. Based on the service order reviewed, the grab bar was ordered on 4/2/26. Maintenance Director and Administrator confirmed that the grab bar was installed in R1's room on 4/9/26.

Based on interviews conducted, documents reviewed, and information collected, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED.

Report is reviewed with administrator, Katherine Tazawa and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2