Peninsula Village

Type of visit: Required - 1 Year

On 07/10/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection. LPA met with administrator Terry Illastron and explained the purpose of today's visit. There is 2 staff and 3 residents present. LPA was allowed entry into the facility. This is a single level facility that is cleared to be all non-ambulatory residents and one bedridden resident in room #4 . Hospice waiver for 2. There are no hospice residents or bedridden residents at this time. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen and observed appliances are in good repair. Knives are stored and locked in the medication closet located in a small hallway near room 1. Medications are observed to be locked in a medication closet which appeared organized and well kept. Perishable and non-perishable food items are observed as in place. There is an additional freezer in the garage area that houses facility food. First aid kit is observed as complete with required items. LPA observed that there are two fire extinguishers in place with an inspection date of 05/05 or 06/2026, smoke detector/carbon monoxide detectors are observed in place through out the facility, and central heating/cooling system in place. Facility is equipped with fire sprinklers through out the physical plant. PPE and additional incontinence supplies are in place. Laundry area is also observed as fully operational located in the garage. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 01/10/2026 per a desk calendar blotter observed. Continued on next page... Page 2 Water temperature was measured at 107F in resident full bathroom adjacent to room 1, another half bath in room 4. All resident rooms contain a half bathroom for resident use. There is a common shower room for residents that use non-skid mats in place. In the full bathroom adjacent to room 1, LPA observed that the tub was not draining properly, with a line of water or soap scum or light mold above the water level observed. The water is about 1in deep and is slowly draining. This requires attention as it is not in good repair at time of visit. By the time LPA left the facility, the tub had fully drained. LPA observed rooms at random and all appeared clean, and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place in a hallway closet adjacent to the dining room. LPA reviewed 3 resident files and also reviewed 3 staff files on this day. Per resident files reviewed, they are current. Per staff files reviewed, all files were current with training and CPR/First Aid. Client medications are inspected and are current including facility medication administration records. Administrator certificate is observed as current forTerry Illastron is expiring on 12/4/2027. The following updated forms are requested to be submitted to CCLD by 07/22/2026: • Copy of administrator certificate • Copy of facility's liability insurance • LIC500 Staff Schedule Citations issued on the following LIC809D page. Report is reviewed with Terry Illastron.the state’s words, verbatim · CDSS document, Jul 15, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 22, 2026

87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This regulation has not been met as evidenced by: Based on observations made, the bathtub/shower adjacent to room 1, had slow draining water and a ring of soap scum or light mold above the observed water level of approximately 1in.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: Facility shall develop a plan of correction in writing, addressing the slow draining tub and cleaning of the tub itself. Evidence shall be received of correction and invoice of repair services if required.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.695(c) · Plan of correction due date: Jul 22, 2026

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. The regulation has not been met as evididenced by: Based on records reviewed, the last drill was conducted on 01/10/2026, not meeting the quarterly requriment. The licensee did not comply with the section cited above, as there is no documentation conducted since 01/10/2026.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: Facility shall develop a plan of correction in writing, to show that drill will be conducted quarterly and a record of such drill will be maintained. Drill to be conducted as soon as possible to meet this requirement.

Allegation investigated: - Licensee did not ensure facility was free from black mold

On 01/21/2026, Licensing Program Analyst (LPA) Jaime Vado conducted an unnannounced complaint inspection visit in regards to the allegation received allegation. LPA met with administrator Terry Illastron and explained the purpose of today's visit. During today's inspection LPA conducted interviews and made observations within the facility. LPA inspected facility bathrooms and did not observe black mold. As part of the investigation, LPA spoke with San Mateo County Code Enforcement as well who made an unannounced inspection visit to the facility on 01/13/2026 and made their own observations. Per their observatons made, there were no signs of what they would consider as black mold. Code Enforcement observed only dust and other signs of regular treatable mold that would not be considered as black mold. The mold described was minor due to condensation on a bathroom ceiling caused by shower steam, that is not considered to be black mold and is cleanable not neading any major renovation or construction to clean as it is wipeable. According to to Code Enforcement, black mold is in the drywall or wood that spreads through out that would need to be removed and replaced via contractors. Per San Mateo Code Enforcement's observations and LPA observations, no black mold was present in resident bathrooms or the facility. This allegation is unfounded. This agency has investigated the complaint alleging, "Licensee did not ensure facility was free from black mold". 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. This report is reveiwed with Terry and a copy is provided on this day. Unfoundedthe state’s words, verbatim · CDSS document, Jan 21, 2026 · control 14-AS-20260113095218

Type of visit: Case Management - Health Checks

On 12/17/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - health check visit. LPA met with caregiver Ed Illiastron and explained the purpose of today's visit. At around 1245, administrator Terry Illiastron The Department received a report of probable meal service in regards to quantity and quality and facility buildings and ground. LPA observed food supplies in place in the main kitchen refrigerator, lunch, and dinner food items. LPA also observed food supplies in the garage as well. All food supplies are observed to be in place. LPA advised on providing enough food to residents to meet USDA standards and for it to be stored and served properly. Food is being cooked during the visit which appeared to be steamed vegetables for dinner. LPA observed defrosted chicken breasts as well to be served for specific residents for dinner. Lunch was observed to be various types of soups. LPA advised proteins to also be served for lunch. LPA toured the facility and observed resident rooms at random including two resident bedrooms and bathrooms within. They were observed to be clean. No odors or debris is observed in the bedrooms and bathrooms. 3 residents are out of the facility at this time attending their day programs. No citations issued. Report is reviewed with Ed and a copy is provided on this day.the state’s words, verbatim · CDSS document, Dec 17, 2025

Type of visit: Required - 1 Year

On 07/10/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced prelicensing inspection. LPA met with administrator Maria Roias and explained the purpose of today's visit. There is 2 staff and 3 residents present. LPA was allowed entry into the facility. This is a single level facility that is cleared to be all non-ambulatory residents and one bedridden resident in room #4 . Hospice waiver for 2. There are no hospice residents or bedridden residents at this time. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen and observed appliances are in good repair. Knives are stored and locked in the medication closet located in a small hallway near room 1. Medications are observed to be locked in a medication closet which appeared organized and well kept. Perishable and non-perishable food items are observed as in place. There is an additional freezer in the garage area that houses facility food. First aid kit is observed as complete with required items. LPA observed that there are two fire extinguishers in place with an inspection date of 05/27/2025, smoke detector/carbon monoxide detectors are observed in place through out the facility, and central heating/cooling system in place. Facility is equipped with fire sprinklers through out the physical plant. PPE and additional incontinence supplies are in place. Laundry area is also observed as fully operational located in the garage. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 06/26/2025. Continued on next page... Page 2 Water temperature was measured at 107F in resident room. All resident rooms contain a half bathroom for resident use. There is a common shower room for residents that use non-skid mats in place. LPA observed rooms at random and all appeared clean, and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place in a hallway closet adjacent to the dining room. LPA reviewed 5 resident files and also reviewed 3 staff files on this day. Per resident files reviewed, they are current. Per staff files reviewed, all files were current with training and CPR/First Aid. Client medications are inspected and are current including facility medication administration records. Administrator certificate is observed as current via the CDSS website as the administrator, Terry Illastron, is expiring on 12/4/2025. The following updated forms are requested to be submitted to CCLD by 07/17/2024: • Copy of facility's liability insurance • LIC308 Designation of responsible staff person • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule • Copy of control of property or copy of lease No citations issued on this day. Report is reviewed with Terry Illastron.the state’s words, verbatim · CDSS document, Jul 10, 2025

Type of visit: Required - 1 Year

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 as well as fenced backyard. There is a 1 car garage, where washer and dryer are located. No accessible bodies of water or fire safety hazards observed. 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, nonskid flooring material, hand washing reminder signs, and liquid soap. Hot water temperature is tested at 105 degrees in room 7 bathroom. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. Three residents are present, and 3 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. Staff have current first-aid training. Terry Illastron is a certified RCFE administrator that oversees facility operations. The following updated forms/information are requested to be submitted to CCLD BY 7/2/24: • LIC 309 Administrative Organization • LIC 308 Designation of Administrative Responsiblity • LIC 500 Personnel REport Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages.. Also, see Technical Advisory Notes--6 pages.the state’s words, verbatim · CDSS document, Jun 18, 2024

The state marks this report as 12 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.