<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200739
Report Date: 08/21/2025
Date Signed: 08/21/2025 05:24:47 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/02/2025 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250502142321
FACILITY NAME:DESIRED PEACE HOME CAREFACILITY NUMBER:
079200739
ADMINISTRATOR:LAM, PAUL, KFACILITY TYPE:
740
ADDRESS:2181 WAYNE DRTELEPHONE:
(510) 759-8889
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 5DATE:
08/21/2025
UNANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Paul Lam, Administrator TIME COMPLETED:
05:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not ensuring that resident is accorded privacy, dignity and respect while in care
Facility did not communicate with resident for non-payments
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 08/21/2025 at 4:40PM, Licensing Program Analyst (LPA), T. Syess-Gibson arrived unannounced to deliver complaint findings for the allegations above. LPA met with Paul Lam, Administrator, and explained the reason for the visit.

During the course of the investigation the LPA interviewed staff, resident, and reviewed and obtained records.

Allegations:
Staff are not ensuring that resident is accorded privacy, dignity and respect while in care
During interviews with S1, S3 and R1 it was revealed that S3 did speak about non-payment of R1’s rent in front of staff and residents. S1, S3 and R1 stated during interviews that R1 brought it to S1’s attention of how uncomfortable R1 felt when S3 was discussing the non-payment in front of others, and that it should’ve been done privately.

Continued on LIC9099C..

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20250502142321
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DESIRED PEACE HOME CARE
FACILITY NUMBER: 079200739
VISIT DATE: 08/21/2025
NARRATIVE
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
Continued from LIC9099


R1 stated during interview, R1 had a lengthy conversation with S1 expressing frustration about how the situation was handled and that S1 did apologize for S3’s actions and agreed to have a conversation with S3. S1 and S3 admitted that the conversation should have been in a more private setting, not in front of other residents.


Facility did not communicate with resident for non-payments
During interviews with S1 and R1 it was revealed that S1 did not communicate with R1 regarding non-payments until R1’s rent wasn’t paid for two (2) months. S1 admitted during interview that S1 never brought up the issue to R1. R1 also stated during interview of having no knowledge of non-payment until the day S3 decided to talk about it in front of the other residents.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.




Exit interview conducted with Paul Lam. A copy of this report and appeal rights provide
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20250502142321
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DESIRED PEACE HOME CARE
FACILITY NUMBER: 079200739
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/28/2025
Section Cited
CCR
87468.1
1
2
3
4
5
6
7
87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to read 87468.1 and send a self certifying email to CCLD by POC date.
8
9
10
11
12
13
14
Based on interviews, licensee did not comply with section cited above by not communicating with resident for nonpayment which poses a potential personal rights risk to the persons in care.
8
9
10
11
12
13
14
Type B
08/28/2025
Section Cited
CCR
87468.2
1
2
3
4
5
6
7
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to read 87468.2 and implement a plan on how facility will communicate regrading resident's nonpayment to CCLD by POC date.
8
9
10
11
12
13
14
Based on interviews, licensee did not comply with section cited above by having a conversation about nonpayment in front of other residents which poses a personal rights risk to the persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/02/2025 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250502142321

FACILITY NAME:DESIRED PEACE HOME CAREFACILITY NUMBER:
079200739
ADMINISTRATOR:LAM, PAUL, KFACILITY TYPE:
740
ADDRESS:2181 WAYNE DRTELEPHONE:
(510) 759-8889
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 5DATE:
08/21/2025
UNANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Paul Lam, Administrator TIME COMPLETED:
05:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure that medications was administer to resident in care
Staff did not ensure that resident care needs were met while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 08/21/2025 at 4:40PM, Licensing Program Analyst (LPA), T. Syess-Gibson arrived unannounced to deliver complaint findings for the allegations above. LPA met with Paul Lam, Administrator, and explained the reason for the visit.

During the course of the investigation the LPA interviewed staff, resident, and reviewed and obtained records.


Allegations:
Staff did not ensure that medications was administer to resident in care
During interviews with staff and resident(R1) it was revealed that R1’s physician made changes to two of R1’s medications. R1 stated during interview, staff stop giving R1 two medications without the doctor’s approval. S1 and S2 stated during interview R1’s physician changed two (2) out of the three (3) medications from daily dosage to as needed (PRN).

Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20250502142321
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DESIRED PEACE HOME CARE
FACILITY NUMBER: 079200739
VISIT DATE: 08/21/2025
NARRATIVE
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
Continued from LIC9099A


During record review it was revealed that R1’s physician changed two (2) out of the three (3) medications from daily dosage to a PRN. The Medication Administer Record (MAR) was also reviewed during the investigation and it revealed medications are being administered to R1 as per the physician’s order.


Staff did not ensure that resident care needs were met while in care
During interviews with S1, S2 and R1 it was revealed that staff does ensure the residents’ care needs are met. R1 stated during interview, staff does a great job assisting her daily needs, ready to live alone without care. S1 and S2 stated during interviews that all residents in care ADLs are handled by staff and that staff have been trained to handle residents’ needs.


Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED.


Exit interview conducted with Paul Lam. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5