Peninsula Village

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.

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... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.

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 and backyard. There is a 1 car garage, where washer and dryer are located. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. 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. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 4 residents 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 health screenings. Staff have current first-aid training. Terry Illastron is a certified RCFE administrator (x 12/23) that oversees facility operations. The following updated forms/information are requested to be submitted to CCLD BY 8/11/22: • Current lease agreement (This was not submitted as requested in 2021) • Current liability insurance • LIC 9282 Infection Control Plan No deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed.. See 2 Technical Advisory Notes for additional information.