Peninsula Senior Living Magnolia

Type of visit: Case Management - Other

On 8/27/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to follow up on an SOC341 received by the Department on 8/19/2026 which was a report of self-neglect of R1. LPA Calandra was greeted by Diana Nguyen, Lead Caregiver/Medtech and Mary Ann Vizconde, Administrator arrived later during the visit. During the visit, LPA Calandra conducted interviews and reviewed documents. According to the Reporting Party, R1 recently lost the use of their hands and legs due to a disease. Based on interviews, R1 does not like to talk about their past and has never expressed self-neglect. Based on interviews and record review, there is no evidence of self-neglect is not occurring at this time. LPA received a copy of the latest Physician's report for R1. No deficiencies cited during today's visit. An exit interview was conducted and a copy of the report provided to the Administrator via email.the state’s words, verbatim · CDSS document, Aug 27, 2026

Type of visit: Case Management - Annual Continuation

To complete annual visit of 12/8/25, LPA Jeung reviewed clients' medications and issued citations for Type B deficiencies observed on 12/8/25, which are cited as per California Code of REgulations, Title 22 on following pages. LPA also reviewed corrections made as per Type A citations issued on 12/8/25. Deficiency is recited and citation appears on following page.the state’s words, verbatim · CDSS document, Jan 5, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Jan 12, 2026

POSTURAL SUPPORTS A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met, as residents in rooms #2, #3, #7, #8, #9, #15, #17, #18, #19, #20 have half bed rails on beds, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jan 5, 2026

Plan of correction: MD orders for half bed rails for clients in rooms #2, #3, #7, #8, #9, #15, #17, #18, #19, #20 will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Jan 12, 2026

REAPPRAISALS The pre-admission appraisal, as specified in Section 87457... shall be updated in writing as frequently as necessary or once every 12 months... to note significant changes in condition...and to keep the appraisal accurate. This requirement is not met, as appraisals for clients #2, #7, #9 are dated over 12 months ago. Licensee failed to ensure that written appraisals are updated annually, which poses a potential health safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jan 5, 2026

Plan of correction: Written appraisals for clients #2, #7, #9 will be updated and sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(h)(1) · Plan of correction due date: Jan 5, 2026

REAPPRAISALS The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every 12 months, either in person or by video appointment...documentation of the annual routine visit...shall be added to the resident's record. This requirement is not met, as MD reports for clients #2 and #9 are dated more than 12 months ago. Licensee failed to ensure that MD reports are completed annually, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jan 5, 2026

Plan of correction: MD reports for clients #2 and #9 will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR87507(a)(1)(A) · Plan of correction due date: Jan 12, 2026

ADMISSION AGREEMENTS The licensee shall complete an individual written admission agreement...text of the admission agreement, including any attachments and modifications, shall be printed in black type of not less than 12-point type size, on plain white paper. The print shall appear on one side of the paper only. This requirement is not met, as original signed admission agreement for client #9 is printed on both sides of paper, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jan 5, 2026

Plan of correction: Plan of correction to be sent to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(f)(1) · Plan of correction due date: Jan 12, 2026

EMERGENCY PLANS A facility shall have...the following in place: An evacuation chair at each stairwell, on or before July 1, 2019. This requirement is not met, as there are no evacuation chairs in 3 stairwells. Licensee failed to ensure that evacuation chairs are installed in each stairwell, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jan 5, 2026

Plan of correction: Evacuation chairs will be installed in each of 3 stairwells, and proof of correction to be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(c)(1) · Plan of correction due date: Jan 12, 2026

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 there is no evidence that staff #1 and #2 have current first-aid training, which poses a potential health, safety or personal rights risk to clients in care. Licensee failed to ensure that all caregivers have current first-aid training.the state’s words, verbatim · CDSS document, Jan 5, 2026

Plan of correction: Proof of current first aid training for staff #1 and #2 will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(a)(1-8,11) · Plan of correction due date: Jan 5, 2026

PERSONNEL RECORDS The licensee shall ensure that personnel records are maintained on... each employee. Each personnel record shall contain...Employee's full name, Social Security number, Date of employment, Written verification that the employee is at least 18 years of age, including...a copy of his/her birth certificate or driver's license, Home address and telephone number, Educational background, Past experience, including...former employers... position for which employed...health screening.... REcords for staff #1 do not include job application and health screeningthe state’s words, verbatim · CDSS document, Jan 5, 2026

Plan of correction: Job application and health screening for staff #1 sent to CCLD on 12/10/25. Deficiency corrected and cleared

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Jan 6, 2026

MAINTENANCE AND 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 temperature tested at 140 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. This deficiency was cited on 12/8/25, but not corrected.the state’s words, verbatim · CDSS document, Jan 5, 2026

Plan of correction: Hot water temperature will be lowered and maintained within range of 105 to 120 degrees F. Proof of correction to be submitted to CCLD BY DUE DATE

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Dec 8, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Dec 9, 2025

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 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.the state’s words, verbatim · CDSS document, Dec 8, 2025

Plan of correction: 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

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(g)(2) · Plan of correction due date: Dec 9, 2025

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 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.the state’s words, verbatim · CDSS document, Dec 8, 2025

Plan of correction: Proof that criminal record clearances for agency staff #3 and #6 are associated to facility will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)5) · Plan of correction due date: Dec 9, 2025

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 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 railsthe state’s words, verbatim · CDSS document, Dec 8, 2025

Plan of correction: Plan of correction to be submitted to CCLD for use or non-use of full bed rails for clients #6 and #7

Type of visit: Required - 1 Year

On December 02, 2024, at 8:50 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. LPA met with the Med tech, Maryanne Williams and disclosed the purpose of the inspection. Manager, Maryann Vizconde arrived shortly after. The manager informed the LPA that the facility currently has 14 residents in care. At 9:10 AM, the LPA initiated a walk-through of the facility, accompanied by the manager. There are (2) floors with (8) bedrooms on the 1st floor and (11) bedrooms on the 2nd floor. All resident rooms are single occupancy with vanity and a bathroom without shower area. At 9:14 AM, LPA inspected random 3 resident rooms on the 1st floor and 6 resident rooms on the 2nd floor, and found them clean, well-lit, and equipped with the required furniture. At 9:26 AM, LPA measured hot water temperatures in random rooms. The hot water temperature at the sink faucet was measured at 151.7°F in room #6 and 136.3°F in room #7 on the 1st floor, and 162.5°F in room #10 and 142.6°F in room #14 on the 2nd floor. At 9:42 AM, the LPA inspected the hallway half bathroom and observed it in clean, sanitary, and operating condition. At 9:46 AM, the LPA inspected the common resident bathroom with shower and found it clean, sanitary, and in good working condition. It contained soap, grab bars, a trash can, non-slip flooring, and a shower chair. At 9:52 AM, the LPA inspected the storage space in the hallway and observed it containing clean linens for residents’ use and found it well organized. At 9:54 AM, LPA inspected the laundry room and observed a washer and dryer in working condition. The elevator was found in operational condition. At 9:58 AM, LPA inspected the dining area and observed it clean, with all the furniture in good repair. Continued on LIC 809-C At 10:02 AM, the LPA inspected the kitchen and found it clean, with no food preparation or cooking in progress at the time. LPA checked the appliances and observed them in working order. LPA inspected the refrigerator and pantry cabinets and observed enough supplies of fresh perishable food for (2) days and nonperishable staples for (7) days. No expired food and no stored medications were noticed. At 10:13 AM, the LPA inspected the fire extinguishers mounted on the hallway wall (on both 1st and 2nd floors) and found they were fully charged with a last service tag of 08/07/2024. The manager tested the smoke and carbon monoxide detector located in the hallway in the LPA's presence, and it was found to be functional. At 10:20 AM, LPA inspected the basement and observed pantry storage area, water heaters and other storage supplies. At 10:26 AM, LPA toured the backyard area and observed patio tables, chairs, and an umbrella for resident use. There were no bodies of water noted and was found clear of obstructions/tripping hazards. At 10.38 AM, the LPA observed a locked centrally stored medication cabinet located inside the med room. Medications were organized in separate bins for each resident. All medication bottles were properly labeled. Centrally Stored Medication Records (CSMR) were reviewed and found to be complete. The LPA inspected the first aid kit and observed it fully stocked. At 10:53 AM, The LPA reviewed (4) staff personnel records and (5) resident records. The LPA observed that 5 of 5 clients had the Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. LPA observed that 4 of 4 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening, and confirmed that 4 of 4 staff members are associated with the facility. At 11:20 AM, the LPA reviewed Emergency Drill Logs and observed Emergency Disaster Drills were not conducted quarterly. The following updated forms are requested to be submitted to CCLD by 12/09/2024: LIC 500: Personnel Report LIC 308: Designation of Facility Responsibility Certificate of Liability Insurance Administrator Certificate(s) Continued on LIC 809-C The deficiencies are being cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted, and Plans of Correction were reviewed and developed with the Manager. A copy of this report and appeal rights were discussed and left with the Manager, Maryann Vizconde, whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Dec 2, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Simi Rai conducted a case management visit to follow up on deficiency cited during the case management visit conducted on 3/21/2024. LPA Rai met with Co-Administrator (CADM) Maryann Vizconde and stated the purpose of the visit. On 3/21/2024, the Licensee was cited facility for R1 was not provided care and supervision to meet R1’s needs wherein R1 left the facility unassisted while facility staff were unaware. On 3/21/2024, CADM, on behalf of Licensee, submitted Plan of Correction. During visit, LPA reviewed and discussed the Plan of Correction with Co-Administrator, Maryann Vizconde. CADM stated the safety meetings are held on a every shift along with the endorsements from one shift to another. CADM has been leading the safety meetings. The follow deficiencies and plan of corrections were reviewed and cleared during the visit: For regulation CCR 87468.1(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities, LPA Rai observed the safety meeting records which will be held every shift. Co-Administrator, Maryann Vizconde stated the facility will install delayed egress doors. LPA Rai advised to review CCR 87705 Care of Persons with Dementia to follow the initial and continuing requirements to be met for the licensee to utilize delayed egress devices on exterior doors or perimeter fence gates. Based on today's inspection visit, the Administrator and staff have corrected all of the above citation/deficiencies. Plan of Correction (POC) clearance is issued and provided to Co-Administrator, Maryann Vizconde. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed Co-Administrator, Maryann Vizconde and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 4, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit today. LPA Rai met with Licensee, Neeru Verma and stated purpose of today's visit. The purpose of the case management visit was to follow up on an incident which occurred on 2/26/2024 at 4:45pm when resident (R1) left the facility unassisted. Per Incident Report, the facility received a phone call from R1's child stating R1 was found by the local law enforcement officers. The incident was reported to the Department via Unusual Incident Report on 2/28/2024. LPA Rai interviewed 2 staff at the facility (LIC & S1). LIC stated the R1 is a Memory Care resident and is unable to leave the facility unassisted as stated in their LIC 602 Physician's Report dated 10/12/2023. LIC stated the resident left the facility from the front door, following after the LIC, wherein the alarm sensor did not capture resident leaving the facility. S1 stated the facility staff were not aware of resident leaving the facility. Facilty staff conducted a routine safety check and it was assessed the resident was not present at the facility. S1 stated the resident left the facility in between the status checks conducted by staff. S1 stated the staff conducted 30 minute status checks on the resident due to the wandering behavior. S1 stated the staff alerted LIC, resident's family and the local law enforcement agency. S1 stated the resident was found 0.2 miles away from the facility by the local law enforcement officer and resident's family member brought resident back to the facilty. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. Exit interview was conducted with Licensee, Neeru Verma and a copy of this report was provided. Appeal Rights were provided.the state’s words, verbatim · CDSS document, Mar 21, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(4) · Plan of correction due date: Mar 22, 2024

Additional Personal Rights of Residents in Privately Operated Facilities:(a)... residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in...qualifications, and competency to meet their needs. This requirement was not met as evidenced by: R1 was not provided care and supervision to meet R1's needs wherein R1 left the facility unassisted while facility staff were unaware which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 21, 2024

Plan of correction: Licensee will submit a written plan of action to ensure resident's safety and provide in-service training by POC date. Licensee agreed and understood.