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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202832
Report Date: 12/08/2025
Date Signed: 12/08/2025 06:49:08 PM

Document Has Been Signed on 12/08/2025 06:49 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: 19DATE:
12/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Ray Salinas and Neeru VermaTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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LPA Jeung toured facility and grounds of this 2 story facility. There are 8 bedrooms on the 1st floor and 11 bedrooms on the 2nd floor. All rooms are private with private half baths, and ground floor rooms each have direct exits to exterior. There is a shower room on each floor. There are 3 stairwells and one elevator. Dining room, kitchen, duty station/medication room and living room with TV are on the ground floor.
On the second floor, there is a crafts/activity room, small library room, laundry room and beauty salon. Medications and toxins are secured and inaccessible to clients. Supplies of food preparation and service items, perishable and non-perishable foods, bed and bath linens and PPE are maintained. Hot water temperature tested randomly in first and second floor rooms. There is an emergency call system installed in private bathrooms, and another pendant alarm that can be worn by residents; an audible signal is transmitted to a monitor in the living room/manager's desk on ground floor, and caregivers are alerted via walkie talkies.
Staff and client files are reviewed. Four residents are currently receiving hospice services. Neeru Verma is a certified RCFE administrator (x 1/27) that oversees facility operations, but certificate is not available for review.
Due to time constraints, citations for Type B deficiencies will be issued at a later date, and medication records will be reviewed then.

The following information/forms are requested to be sent to CCLD BY 12/22/25:
- Administrative Organization (LIC309)
- Personnel Report (LIC500)
- Facility sketch (LIC999) with corrected room numbers
- Bedridden plan of operation
- Personnel Policies
- proof of current liability insurance

Type A deficiencies of the California Code of Regulations, Title 22, are cited on a following page.
NAME OF LICENSING PROGRAM MANAGER: Cowan April
NAME OF LICENSING PROGRAM ANALYST: Audrey Jeung
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2025
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 12/08/2025 06:49 PM - It Cannot Be Edited


Created By: Audrey Jeung On 12/08/2025 at 05:49 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: 12/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2025
Section Cited
CCR
87303(e)(2)

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MAINTENANCE & 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 to 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 124 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.
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Type A
12/09/2025
Section Cited
CCR87411(g)(2)

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PERSONNEL REQUIREMENTS GENL
Prior to employment or initial presence in the facility, all employees...subject to a criminal record review shall obtain a CA clearance...as required by law or Dept regulations or request a transfer of a criminal record clearance...This requirement is not
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Proof that criminal record clearances for agency staff #3 and #6 are associated to facility will be sent to CCLD BY DUE DATE
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met, as agency caregivers are present, but their criminal record clearances are not associated to facility. Licensee failed to ensure that caregivers maintain criminal record clearance & association to facility, which poses an immediated health, safety or personal rights risk to clients.
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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: 12/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/08/2025 06:49 PM - It Cannot Be Edited


Created By: Audrey Jeung On 12/08/2025 at 06:07 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: 12/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2025
Section Cited
CCR
87608(a)5)

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POSTURAL SUPPORTS
Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met, as
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Plan of correction to be submitted to CCLD for use or non-use of full bed rails for clients #6 and #7
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full bed rails are observed on beds of nonhospice clients, which poses an immedicate health, safety or personal rights risk to clients. Licensee failed to ensure that full bed rails are only used for hospice clients when included in hospice care plans. Clients #6 & #7 have full bed rails
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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: 12/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2025


LIC809 (FAS) - (06/04)
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