Inspection Report Summary
Most inspections at Peninsula Regent Continuing Care Retirement Community found deficiencies, with the most recent annual inspection on December 2, 2024, identifying issues related to personnel health screenings, staff training, admission agreement documentation, and first aid training. A complaint investigation on September 27, 2024, substantiated concerns about delayed responses to call button alerts and a resident injury caused by rough handling, which led to the termination of the involved staff member. Other complaint allegations about bathing and toileting assistance were unsubstantiated. Earlier visits, including one in October 2022, found no deficiencies, indicating some fluctuations in compliance over time. The issues primarily involved staff training, documentation, and resident care, with no fines or enforcement actions listed in the available reports.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
47% occupied
Based on a December 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 206
Capacity: 435
Deficiencies: 4
Dec 2, 2024
Visit Reason
The inspection was a required unannounced 1-year annual inspection visit to evaluate compliance with regulations at the Peninsula Regent Continuing Care Retirement Community.
Findings
The inspection found multiple deficiencies related to personnel health screenings, staff training, admission agreement documentation, and first aid training. The facility had no fire safety hazards and maintained appropriate safety measures, but failed to maintain required health screenings and training documentation for several staff members.
Deficiencies (4)
| Description |
|---|
| Health screenings and TB test results for staff #1 and #2 are not maintained. |
| No evidence that care staff have received required training on postural supports and restricted health conditions. |
| Admission/residency agreements for clients #1, #2, #3, #5 are printed on both sides of paper, not complying with printing requirements. |
| Proof of current first-aid training for staff #2 and #3 is not maintained. |
Report Facts
Staff files reviewed: 6
Staff files with deficiencies: 2
Client files reviewed: 6
Client files with deficiencies: 4
Staff files with first aid training deficiencies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Martin Herter | Administrator | Facility administrator overseeing operations |
| Audrey Jeung | Licensing Program Analyst | Conducted the facility inspection and evaluation |
| April Cowan | Licensing Program Manager | Supervisor of the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 203
Capacity: 435
Deficiencies: 2
Sep 27, 2024
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations including untimely response to call button alerts, resident injury, inappropriate staff behavior, and rough handling of residents.
Findings
The investigation substantiated allegations that staff failed to respond timely to call button alerts and that a resident sustained injuries due to rough handling by a staff member who was subsequently terminated. Other allegations regarding bathing and toileting assistance were unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated based on evidence including emergency call logs showing delayed staff responses and documentation of a staff member causing bruises and a skin tear to a resident. The staff member was terminated. Other allegations related to bathing and toileting assistance were unsubstantiated due to lack of sufficient evidence.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff failed to respond to client's call alerts in a timely manner, posing potential health, safety, or personal rights risk. | Type B |
| Client sustained an injury when a staff handled client in a rough manner, violating personal rights. | Type B |
Report Facts
Delayed staff responses: 16
Facility capacity: 435
Resident census: 203
Plan of Correction due date: Oct 4, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Martin Herter | Administrator | Met with during investigation. |
| Audrey Jeung | Licensing Program Analyst | Conducted the complaint investigation. |
| April Cowan | Licensing Program Manager | Oversaw the complaint investigation. |
Inspection Report
Census: 196
Capacity: 435
Deficiencies: 0
Oct 6, 2022
Visit Reason
The visit was conducted as a Case Management - Health Checks in response to a Death Report submitted on 10/4/22.
Findings
The licensing analysts met with the director of health and wellness, reviewed the admission agreement and facility monitoring information for independent residents, and obtained staff schedules and client rosters. No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cara Smith | Licensing Program Manager | Named as Licensing Program Manager overseeing the visit. |
| Audrey Jeung | Licensing Program Analyst | Named as Licensing Program Analyst conducting the visit. |
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