Peninsula Reflections

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Case Management - Incident

On 8/13/2026, LPA Grace Donato conducted an unannounced case management visit in relation to an incident that was reported on 7/31/2026. LPA met with Wellness Director (WD) Rowena Cancino & Executive Director Anna Allas and explained the purpose of the visit. An incident report was received by Licensing regarding a theft that occurred in the facility. A staff (S1) stole an item and pawned it. Facility was not aware of the incident until the family contacted the facility. When the facility was made aware, an investigation was started and the police was involved. The item were since returned to the family and S1 is no longer working in the facility. LPA is waiting for the police report to be made available. No citations issued today. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Aug 13, 2026

Type of visit: Case Management - Incident

On 7/3/2026, LPA Grace Donato conducted an unannounced case management visit in relation to an incident that occurred on 6/15/2026. LPA met with Wellness Director (WD) Rowena Cancino & Executive Director Anna Allas and explained the purpose of the visit. An incident report was received by Licensing regarding a resident (R1) who was able to leave facility at around 3:30am. Resident was accompanied back by a police officer. LPA reviewed the facility video and LPA observed R1 to be forcing the door open to go out the facility. R1 repeatedly forced open the door until it opened. Based on interviews, WD mentioned that R1s routine is to play with the computer on the activity room around 3am then go back to the bedroom. Night staff, during this time, were doing routine rounds when R1 was observed not to be in the bedroom. Night staff right away went looking for the R1. Upon R1s return, staff assessed R1 and found no injuries. The facility has since updated R1s needs and services plan. R1 has no known wandering tendencies. No citations issued today. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Jul 3, 2026

Allegation investigated: Staff did not answer residents calls for assistance Staff could not communicate with emergency personnel Staff did not have access to residents emergency paperwork for Emergency personnel

On December 5, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Activities Director, Nancy Medina and explained the purpose of the visit. Regarding the allegation, staff did not answer residents call for assistance, according to the reporting party, on June 16, 2025, emergency personnel responded to the facility for a resident (R1) complaining of body pain. According to the reporting party, when emergency personnel responded to the facility and went to the second floor, there were no staff member to be seen and R1 was yelling for yelp. In addition, reporting party indicated that R1 was yelling for help for over two hours with no staff attending R1's needs. During the investigation, LPA interviewed the staff on shift that night. According to Staff 1 (S1), he/she worked on the second floor, Staff 2 (S2) worked on the first floor and Staff 3 (S3) was working on both floors. S1 and S2 indicated that they did not hear R1 yelling for help. S1 stated that R1 was on his/her cell phone when he/she checked on R1. (continue to 9099C) Unsubstantiated In addition, S1 and S3 indicated that R1 wanted his/her medication, however they had to keep explaining to R1 that the medication he/she was requesting for is prescribed to be given once every 8 hours, however they made sure that R1 was being checked on every 1-2 hours. Regarding the allegation, staff could not communicate with emergency personnel, according to the reporting party, on June 16, 2025, when emergency personnel arrived to the facility, they requested R1's paperwork, however the staff was Spanish speaking only and radioed another staff member. During the investigation, LPA interviewed staff who were on shift on June 16, 2025. According to Staff 1 (S1), when emergency personnel arrived, S1 admitted he/she had to call S3, the med-tech on shift because S1 speaks Spanish and very little English. In addition, according to 3/3 staff interviewed, although they do not speak a lot of English, they are able to communicate and understand basic English. Regarding the allegation, staff did not have access to residents emergency paperwork for emergency personnel, according to the reporting party, on June 16, 2025, when emergency personnel responded to the facility, they requested for R1's file, however after 10 minutes of waiting, a firefighter went to the staff to see where the file was and was told by staff that they were on the phone with someone (unknown) trying to figure out to to get R1's file. During the investigation, LPA interviewed staff on shift and observed the med-tech room where all resident files are located. Based on observations, LPA observed all resident files available and located in the med-tech office room. According to S3, he/she indicated that normally when staff call 911, the updated system papers are printed and ready for emergency personnel, however, the night of June 16, 2025, R1 called 911 without staff knowing and the papers were not ready so S3 had to go to the med-tech room and print R1's paperwork which took some time as the S3 indicated he/she was experiencing printer issues. According to S3, although it took time to print R1's paperwork, it was eventually printed and provided to emergency personnel. Based on interviews conducted 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 the Activities Director and a copy is provided.the state’s words, verbatim · CDSS document, Dec 5, 2025 · control 14-AS-20250701130341

Allegation investigated: Due to staff neglect, resident sustained a pressure injury Staff retained a resident with a prohibited health condition Staff did not notify authorized representative of change in condition

On November 5, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Anna Allas and explained the purpose of the visit. Regarding the allegation, due to staff neglect, resident sustained a pressure injury in care, according to the reporting party, on May 14, 2025, a Registered Nurse (RN) from Home Health found pressure wounds on Resident 1’s (R1’s) feet and an open Stage IV sacral pressure wound. The facility’s LVN was educated on wound care and staff were reminded to ensure R1 is being repositioned and monitored for hydration and eating for wound healing and overall health, however according to reporting party it was observed that R1 sat in a wheelchair for 6-8 hours a day before the wound was reported on May 14, 2025. During the investigation, LPA interviewed the administrator, staff, reviewed R1’s file; including but not limited to, service plan, home health notes, hospice notes, charting notes, repositioning log, etc. According to the administrator, when R1 was admitted to the facility, R1 did not have any wounds or pressure injuries, however there was redness on R1’s sacrum that was noted. (continue to 9099C) Unsubstantiated On 3/16/25, a nurse from Sutter Care Home came to assess R1 for the appropriate services that's required for R1's needs. Based on the nurse's assessment from Sutter Care, R1 was admitted to hospice on 3/22/25. R1's responsible party revoked hospice services on 4/6/25. Starting 4/1/25, home health started visiting R1 for physical therapy and continued to come 1-2x a week for leg exercises. Based on R1's progress notes reviewed, on 5/9/25, the facility observed an open wound on R1's sacrum. The facility notified R1's physician and the physician ordered home health to evaluate R1's wound. On 5/14/25, R1 was assessed by Sutter Care at Home who indicated that R1 had a pressure ulcer to sacrum. According to staff interviewed, the facility notified R1's physician, responsible party, and updated R1's care plan. Based on R1's care plan, the facility repositioned R1 every two hours, followed the treatment plan that was provided by home health, and monitored R1 for any changes of condition. In addition, home health was coming 2-3x a week for wound care. Based on the repositioning log, R1 was being repositioned every two hours. According to interviews conducted, med-techs were instructed to call hospice when R1's dressing needed to be changed or was soiled if the facility LVN was not present at the facility. In addition, according to the administrator, R1 had a one-on-one caregiver 24/7 who was also trained to change R1's dressing. Regarding the allegation, staff retained a resident with a prohibited health condition, according to the reporting party, on 5/14/25, R1 was found to have an open stage IV sacral pressure wound. During the investigation, LPA interviewed the administrator and reviewed R1’s file. According to documents reviewed, on 5/23/25, a wound nurse came to visit R1 and determined R1's sacral wound was unstageable. According to the Department's and facility's records reviewed, after the administrator was notified that the sacrum pressure injury was unstageable on 5/23/25, an exception request was submitted to Community Care Licensing the same day to request for the facility to continue providing care to R1 who had a prohibited health condition. Regarding the allegation, staff did not notify authorized representative of change in condition, on May 14, 2025, it was found that R1 had pressure wounds on his/her feet and an open stage IV sacral pressure wound, however R1’s authorized representative was not notified about the wound until May 21, 2025. (Continue to 9099C) During the investigation, LPA interviewed the administrator, reviewed home health notes, R1's charting notes, progress notes, and service plan. Based on home health document dated 5/14/25, R1 was observed to have a pressure ulcer to the sacrum. According to the administrator and service plan reviewed dated 5/14/25, the LVN updated the service plan due to change of condition, in specific to active pressure ulcer on heel and sacrum. Based on the progress reports and charting notes reviewed, R1's responsible party was contacted on 5/16/25 regarding the presence of the sacral wound. 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 the administrator and a copy is provided.the state’s words, verbatim · CDSS document, Nov 5, 2025 · control 14-AS-20250722131624

Type of visit: Required - 1 Year

On 10/20/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with the administrator Anna Allas and explained the purpose of today's visit. There are currently 35 residents in the facility during this inspection and multiple staff through out the facility. This is a multi-level facility, Age range 60 and over. Approved for 57 non-ambulatory of which 20 may be bedridden. Maximum of 6 non-ambulatory and no bedridden allowed on second floor. Hospice waiver for 10 residents. There are 5 residents under hospice care as of today's visit. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. Large dining room is clean and organized for residents. LPA observed dining menu and activities calendar posted. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Per staff, all appliances are in working condition. Knives are stored and locked and secured in the kitchen. Perishable and non-perishable food supplies are observed as in place. Kitchen grade fire extinguisher is observed as in place and with an inspection date of 03/29/2025. There are additional food supplies, emergency food supplies, freezers, PPE, and water stored in a storage building at the front of the property on Collins Ave. These are observed as in place. Next to that is another building where the marketing office and employee break room is located. First aid kits are observed as complete with required items as observed. Medications are observed to be locked in the medication rooms and medication cart. Cart is in place near the facility dining room to disperse medication to residents during meal times and is able to be brought through out the community. LPA observed multiple residents in the activity room with 2 staff present. Continued on next page... Page 2 LPA reviewed resident medications at random and observed them as current, stored correctly, and documented via electronic medication administration record system. LPA observed that there are multiple fire extinguishers in place on each floor with an inspection date of 03/29/2025. Smoke detectors, carbon monoxide detectors, and full fire sprinkler system is observed in place through out the facility. Central heating and air conditioning is in place. Laundry room is also observed as fully operational and organized. Lint areas are being cleaned on this day and LPA observed them as clear of lint. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Evacuation chairs are in place in emergency exit stairwells as well. Last emergency/disaster drill was conducted in 07/24/2025. Water temperature was measured in resident rooms 20 and 35. Both were measured at 120F. LPA observed 5 resident rooms at random. All are observed to be free of odors and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place stored in various areas and in the laundry room. LPA reviewed five staff files and 5 resident files during today's inspection and all files are observed as current. Staff are actively conducting training and it is observed as current for the staff reviewed Administrator certificate is current expiring 05/01/2027. No citations issued. Report is reviewed with Anna Allas and a copy is provided on this day.the state’s words, verbatim · CDSS document, Oct 20, 2025

Type of visit: Case Management - Incident

On December 20, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit in relation to an incident that occurred on 12/6/24. LPA met with Activities Director, Nancy Medina and explained the purpose of the visit. The Licensee reported on 12/6/24, Resident 1 (R1) reported that Staff 1 (S1) threw a call light at him/her and his his/her head. According to R1, he/she told S1 that he/she will report S1 to the facility. S1 told R1 that if he/she reported S1 to the facility, he/she will kill R1. 911 was called. The facility assessed R1 for any visible injuries. No injuries were notes. Facility spoke to R1's responsible party who indicated that R1 says things like that even when R1 was at home. In addition, R1's responsible party indicated that whatever R1 said did not happen. During the visit, LPA attempted to interview R1, reviewed R1's file and interviewed the Activities Director. According to the Activities Director, this was an alleged incident and the facility found no evidence to prove that S1 actually did hit R1 with a call light. In addition, according to the Activities Director, R1 has dementia. LPA reviewed R1's file. Based on documentation reviewed, R1 has a diagnosis of dementia, and gets confused, aggressive and has inappropriate behaviors. LPA attempted to interview R1 but due to the language barrier and dementia diagnosis, LPA was not able to get much information from R1. R1 mentioned he likes the staff here and does not have many issues at this facility. No citations are issued during the visit. LPA reviewed report with the Activities Director and a copy is provided.the state’s words, verbatim · CDSS document, Dec 20, 2024

Type of visit: Case Management - Incident

On September 30, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit to follow up on an incident that occurred on 9/21/24. LPA met with Activities Director, Nancy Medina and explained the purpose of the visit. On September 24, 2024, Licensee reported that Resident 1 (R1) was found outside along the driveway of the facility. According to the Licensee, a bystander observed R1 climbing the metal gate and was able to get out. Bystander was trying to redirect R1 until staff came out to get R1. Skin abrasions were noted. During the visit today, LPA conducted interviews and reviewed R1's file. According to file reviewed, R1 has a diagnosis of Alzheimer's Dementia and is unable to leave the facility unassisted. LPA did not observe any reappraisal for R1 after R1 eloped on 9/21/24. In addition, during the file review, LPA observed that R1's physician's report is dated from 2/28/23. Facility failed to ensure an updated annual medical assessment/ physician's report is maintained in R1's file. According to the Administrator, R1 used the exit door in the dining room and gained access to the courtyard and climbed up the metal gate. In addition, the administrator was unable to provide information on why the staff didn't hear the auditory alarm when R1 opened the exit door and why staff was unable to respond immediately. Based on staff interviewed, it was indicated that staff were assisting other residents and was unable to respond immediately. During the visit today, LPA opened the exit door in the dining room to ensure alarms were on and functioning. It was observed the alarm was on and in good repair. Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page. Report is reviewed with Activities Director and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Sep 30, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Oct 7, 2024

87464 Basic Services (f)- Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). Violation of this regulation is not met as evidenced by: Based on file reviewed, it was noted R1 has a diagnosis of late onset Alzheimer's dementia and is unable to leave the facility unassisted. In addition, based on staff interviewed, the alarm did turn on when R1 opened the exit door in the dining room, however staff were assisting other residents and was not able to respond timely. Nevertheless, facility failed to ensure there was proper supervision resulting in R1 eloping from the facility.the state’s words, verbatim · CDSS document, Sep 30, 2024

Plan of correction: Facility will conduct in-service training with staff regarding elopmenet protocols and submit a copy of the training log to LPA by 10/7/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(c)(5) · Plan of correction due date: Oct 7, 2024

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually... Violation of this regulation is not met as evidenced by: During file reviews, LPA observed R1 has a diagnosis of late onset Alzheimer's Dementia and the medical assessment/physician's report maintained in R1's file is from 2/28/2023. Facility failed to ensure an updated annual medical assessment/ physician's report is maintained in R1's file.the state’s words, verbatim · CDSS document, Sep 30, 2024

Plan of correction: Facility to contact R1's physician to get a new updated physician's report and send a copy to LPA by 10/7/24.

Type of visit: Required - 1 Year

On September 17, 2024, Licensing Program Analysts (LPAs) Kiran Jain and Komal Charitra arrived at the facility at 09:15 AM to conduct the Annual 1-year required inspection. LPAs met with Nancy Medina, Activity Director and explained the purpose of the visit. Anna Allas, Administrator joined shortly after. LPAs toured the physical plant and observed it to be clean and odor-free at a comfortable temperature. This is a two-story building with 21 resident bedrooms, 21 bathrooms, a dining room, a living room, an activity area, a storage/supply room, a kitchen, a laundry room, a medication room, and offices on the first level. The second level has 13 resident bedrooms, 13 bathrooms, storage rooms, and a spa room. Delayed Egress was observed to be working properly at the main entrance door. Auditory devices were observed to be in place to monitor all exits. No accessible bodies of water or hazards were observed. Video surveillance was observed only in the hallways and common areas of the facility. The fire extinguishers were fully charged and last serviced on April 2024. The smoke detector and carbon monoxide detector were fully operational. LPAs inspected resident’s rooms and bathrooms at random. Rooms were observed to be clean with the required furniture and sufficient lighting. The bathrooms were observed to be mold-free and equipped with grab bars, liquid soap, and paper towels. The hot water temperature in the resident's bathroom was measured on the first floor in room 10 at 108.6°F. Hot water temperature was also measured on the second floor in room 23 at 118.4°F. Sharp objects, detergents, poisons, and soap were observed to be locked and inaccessible to persons in care. No expired food items were observed. The facility had the required 7 days of non-perishables and 2 days of perishables. LPAs reviewed five resident records and five staff records. All were observed to be complete. Emergency drills are conducted monthly with the last drill documented on September 2024. The resident’s medications are securely stored in a locked cart/cabinet/refrigerator. Medication administration records (MARs) were reviewed, and no expired medications were observed. The First Aid kit was checked and observed to be complete. The following updated forms are requested to be submitted to CCLD by 09/24/2024: · LIC500: Personnel Report · LIC308: Designation of Facility Responsibility · LIC400: Resident Cash Resources · Administrator Certificate · Current Liability Insurance No deficiencies were cited during today's visit. An exit interview was conducted. This report was reviewed with Anna Allas, Administrator, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 17, 2024

Allegation investigated: - Facility staff are attempting to illegally evict resident

On 05/14/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver findings regarding the allegations received. LPA met with the administrator Anna Allas and explained the purpose of today's visit. During the investigation LPA conducted interviews and reviewed pertinent documents regarding the resident's admission agreement and status at the facility. According to documentation reviewed show that the resident was not formally evicted by the facility until 05/13/2024 with an formal eviction notice. The resident is under respite services under contract with him/her hospital. The contract reviewed states that the contract is set to expire on 05/13/2024 and also advised on the initiation of sending him/her to the hospital to continue services due to the expiration of the contract. The facility did not initiate the eviction. Additionally it was found that the hospital the resident is under respite contract with discontinued the refills so the resident can utilize the insurance plan with San Francisco. The facility only initiated emergency services in order for the resident to receive the medication via hospital emergency room out of precaution due to the resident refusing to pay for the medication himself/herself. It was not to evict per interviews. This allegation is unfounded. This agency has investigated the complaint alleging: Facility staff are attempting to illegally evict resident. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Report is reviewed with administrator. Copy is provided. Unfoundedthe state’s words, verbatim · CDSS document, May 14, 2024 · control 14-AS-20240510114244

Allegation investigated: - Staff are mismanaging resident's medication

On 04/26/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver findings regarding the allegations received. LPA met with the admininstrator Anna Allas and explained the purpose of today's visit. During the course of the investigation LPA conducted interviews, made facility observations, and reviewed records. Per records reviewed regarding medication, the medication is marked as being administered accurately. Interviews with staff indicate that the resident did swallow the medication when it was provided and the med tech spoke to the resident during this time to ensure it was swallowed. The med tech confirmed this observation. Due to contradicting interview details this allegation is unsubstantiated. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 26, 2024 · control 14-AS-20240214151800

Type of visit: Case Management - Incident

On 02/15/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - incident visit regarding a police visit to the facility made on this day in the morning hours. LPA met with administrator Anna Allas and explained the purpose of today's visit. During complaint visit made on this day regarding complaint #14-AS-20240214151800. LPA was informed by Anna that the police department came to the facility in the morning hours today regarding medications that R1 supposedly had and where it came from and also the room door of R1 being locked. Staff demonstrated to the officer how the room is unlockable from the outside and how they unlock it. Responding officer provided the facility with a police report number regarding the visit. Police took no further actions during the visit. Facility will provide an incident regarding the police visit. F No citations issued. Report reviewed with Anna.the state’s words, verbatim · CDSS document, Feb 15, 2024

Allegation investigated: - Staff did not prevent another resident from entering resident's room - Staff do not respond to residents' call buttons in timely manner - Staff are unable to communicate with residents due to a language barrier - Staff do not prevent another resident from waking resident - Staff put a resident in residents room that is not compatable with resident.

On 02/07/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the allegations received. LPA met with Nancy Medina and explained the purpose of today's visit. During the investigation LPA conducted interviews and reviewed resident documents. The resident entering the room of R1 had dementia. This facility is an all dementia facility and rooms do have locks that are accessible by staff via key, but for safety reasons staff do not lock doors. As a result of the resident entering the room of R1, staff began to close and lock the door of R1 as requested by R1 since R1 does not have dementia. Call button requests made by R1 were met to the best of the facilities abilities as there are cargivers assigened to groups of residents. Staff responded accordingly based on operational needs and requirements at the times the requests were made. A delay may have incurred, but not based in intent, but staff availability to respond as staff do help other residents in care. R1 does not have one on one caregiving. Continued on next page... Unsubstantiated Page 2 - LIC9099 Staff in the facility are able to communicate to residents as necessary. Some staff do have difficulty but not to the point of not understanding. Those staff with a language barrier, do have resources such as other staff to assist in translation, and have the ability to communicate using translation devices. R1's room mate was diagnosed with dementia and would wake up at random hours during the night due to diagnosis such as sundowning. As a result, the facility moved the room mate and provided R1 with a private room despite only paying for a single bed, not a double, and was able to stay in the room for the duration of their time of the facility. The room mate was deemed compatible at the time of assessmentsm but when the room mates behavior changed, the facility moved the room mate to a better compatible room which provided R1 with their own room. The facility attempted to meet the needs of R1 at all times and made adjustments where needed. The facility communicated with R1 and the social worker of R1 to collaborate and continue to meet the needs and requests made by R1. These allegations are unsubstantiated. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Report is reviewed with Nancy.the state’s words, verbatim · CDSS document, Feb 7, 2024 · control 14-AS-20231113115810