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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609929
Report Date: 04/23/2021
Date Signed: 04/26/2021 08:44:26 AM

Document Has Been Signed on 04/26/2021 08:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:A PEACE OF HOMEFACILITY NUMBER:
567609929
ADMINISTRATOR:PEREY, HERBERT M.FACILITY TYPE:
740
ADDRESS:1227 MIKA WAYTELEPHONE:
(805) 278-9620
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 6CENSUS: 4DATE:
04/23/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Herbert PereyTIME COMPLETED:
04:21 PM
NARRATIVE
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This Case management visit was conducted to address the deficiencies noted during complaint control # 29-AS-20210415142327 investigation visit conducted on 4/23/21.

During facility tour on 4/23/21 starting at 12:50 PM LPA's observed fabric softener, hammer, screwdriver, power drill. bleach, Fabuloso, dish soap, windex, in an unlocked garage accessible to residents. At 12:57 PM LPA's observed a full bed rail on resident #1( R1) bed, no physicians order on file. Starting at 12:59 PM LPA's observed fabric softener, windex, air freshener and bleach wipes in an unlocked laundry room accessible to residents. At 1:01 PM, LPA's observed Iodine, scissors, alcohol preps wipes in an unlocked hallway cabinet accessible to residents. At 1:15PM LPA's observed Fabuloso multi-purpose cleaner and bleach in a backyard washing station accessible to residents. At 1:17PM LPA's observed shovel and rakes in the backyard accessible to residents. During the review of resident records on 4/23/21, starting at 1:58PM, LPA's observed R1, R2 and R3 Physicians Report and Appraisal Reports not currently dated.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):

Exit interview conducted, todays reports reviewed and email to administrator.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE: DATE: 04/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 04/26/2021 08:44 AM - It Cannot Be Edited


Created By: Angel Ascencio On 04/23/2021 at 03:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A PEACE OF HOME
FACILITY NUMBER: 567609929

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/24/2021
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by
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Staff placed items in an inaccessible location during facility visit. Administrator stated that he will provide documentation of scheduled staff training regarding regulation 87705(f)(2).
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Based on LPA's observations, the licensee did not comply with the section cited above as toxic substances were observed throughout the facility accessible to residents which posed an immediate health risk to persons in care.
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Type A
04/24/2021
Section Cited
CCR87705(f)(1)

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87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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Staff placed items in an inaccessible location during facility visit. Administrator stated that he will provide documentation of scheduled staff training regarding regulation 87705(f)(1).
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Based on LPA's observations, the licensee did not comply with the section cited above as scissors, hammer, screwdriver and power drill was observed accessible to residents which posed an immediate health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Angel Ascencio
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/26/2021 08:44 AM - It Cannot Be Edited


Created By: Angel Ascencio On 04/23/2021 at 03:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A PEACE OF HOME
FACILITY NUMBER: 567609929

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2021
Section Cited
CCR
87608(a)(5)(B)

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87608 Postural Supports (a)(5)(B) Under no circumstances shall postural supports include tying, depriving...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 evidence by:
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Administrator stated that he will proved documentation of hospice care plan indicating full bed rails.
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Based on our observations and record review, the licensee did not comply with the section cited above as R1's hospice care plan does not specify the need for full bed rails which poses a potential safety risk to persons in care.
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Type B
04/30/2021
Section Cited
CCR87705(c)(5)

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87705 Care of Persons with Dementia (c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually...

This requirement is not met as evidence by:
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Admin stated they will provide copies of R1, R2 and R3 current signed annual medical assessment and appreasals.
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Based on record review, the licensee did not comply with the section cited above in 3 out of 4 resident records which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Angel Ascencio
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2021


LIC809 (FAS) - (06/04)
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