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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609929
Report Date: 12/18/2025
Date Signed: 12/18/2025 02:45:59 PM

Document Has Been Signed on 12/18/2025 02:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:A PEACE OF HOMEFACILITY NUMBER:
567609929
ADMINISTRATOR/
DIRECTOR:		PEREY, HERBERT M.FACILITY TYPE:
740
ADDRESS:1227 MIKA WAYTELEPHONE:
(805) 278-9620
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 6CENSUS: 4DATE:
12/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:46 AM
MET WITH:Mischelle Perey and Herbert PereyTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 10:49 AM. LPA met with facility staff who contacted the facility Administrator Herbert Perey. The Co-Administrator Mischelle Perey arrived to the facility at approximately 11:10 AM. LPA and Co-Administrator were later joined by Administrator. Entrance interview was conducted and the reason for the visit was explained.

Beginning at approximately 10:50 AM the LPA, along with the facility staff and later the Administrator and Co-Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

COMMON AREAS: This includes the living room, hallway, and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contained a television, adequate seating, and locked storage for resident medication and files. Additionally, the living room was observed to contain all required postings, the facility telephone, emergency flashlights, and a complete first aid kit. The hallway was observed to be clean and free from any obstructions. The hallway contained closets that contained storage for linens and care supplies. Additionally, the hallway contained a locked laundry room which contained the facility’s washer and dryer in addition to laundry chemicals and care supplies. The dining area was observed to be equipped with adequate seating for resident use and contained an appropriately screened fireplace. Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: A PEACE OF HOME
FACILITY NUMBER: 567609929
VISIT DATE: 12/18/2025
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COMMON AREAS CONT.: LPA observed the dining area and hallway to contain wall mounted fire extinguishers that were fully charged and last serviced on 05/14/2024 which was more than 12 months from the inspection date. LPA informed the Co-Administrator who purchased new fire extinguishers during the visit and installed them at the facility. The facility’s fire and carbon monoxide alarms were tested at 12:14 PM and were functional at the time of the visit. All exits in the facility were observed to contain functioning auditory alarms.

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured under-sink cabinet to contain cleaning chemicals. LPA observed secured drawers to contain knives and other sharp objects.

BEDROOMS: There are four (4) bedrooms in the facility; two (2) are dual occupancy resident rooms, two (2) are single occupancy resident rooms. LPA and the Co- Administrator toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

BATHROOMS: There are two (2) bathrooms at the facility. One is designated as a shared/common resident bathroom and one (1) is a private resident bathroom. Both resident bathrooms were observed to be clean and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured to be between 129.3 and 133.3 degrees Fahrenheit, whish is outside of the range required by regulations. LPA informed the Administrator who adjusted the temperature regulator on the water heater and agreed to submit proof of appropriate water temperature to LPA. The private bathroom contained a secured storage which contained grooming supplies.

Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: A PEACE OF HOME
FACILITY NUMBER: 567609929
VISIT DATE: 12/18/2025
NARRATIVE
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GARAGE: The garage was observed to be locked and inaccessible to clients in care. LPA observed the garage to contain an extra refrigerator/freezer, extra care supplies, and sufficient emergency water supplies. LPA observed the garage to contain two (2) makeshift bedrooms which included supports, wooden walls, and a door. LPA interviewed the Co-Administrator about the rooms. The Co-Administrator stated that the rooms were installed in June of 2025 and facility staff were utilizing the rooms. The Co-Administrator confirmed that they did not obtain building permits for the two (2) rooms, did not inform Community Care Licensing Division (CCLD) of the construction, and did not obtain a fire inspection for the rooms. LPA informed the Administrator and Co-Administrator that the constructed rooms are a violation of the facility’s fire clearance which is a zero-tolerance violation and an immediate civil penalty of $500 is being assessed on today’s date (12/18/2025). LPA informed the Administrator and Co-Administrator that failure to remove the structures could result in the assessment of additional civil penalties.

OUTDOOR SPACE: The facility has one (1) emergency exit gate located on the side of the facility; LPA observed clear passageways for emergency exit use. The facility had adequate shaded seating outdoors for resident use. LPA observed cameras throughout the outdoors of the facility.

RECORD REVIEW: Record review began at 12:19 PM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Five (5) staff files were reviewed. All staff files contained all required documentation and trainings. Four (4) resident files were reviewed. All resident files contained the required documentation.

MEDICATION REVIEW: Medication review began at 01:14 PM. Medications for two (2) of four (4) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review.

Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: A PEACE OF HOME
FACILITY NUMBER: 567609929
VISIT DATE: 12/18/2025
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INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last logged emergency disaster drill was conducted on 12/01/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator.

INTERVIEWS: LPA interviewed two (2) residents. The residents interviewed stated that staff treat them well and are attentive to their needs. The residents interviewed had no concerns with the facility. LPA interviewed two (2) staff members. The staff members interviewed were knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and current liability insurance.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited and civil penalty assessed. (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/18/2025 02:45 PM - It Cannot Be Edited


Created By: Trevor Byrne On 12/18/2025 at 02:15 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: 12/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as two fire extinguishers were not serviced annually and two (2) unapproved bedrooms were constructed in the facility garage without proper building permits or fire clearance which poses an immediate safety risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
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Administrator purchased new fire extinguishers at the time of the inspection. Administrator agreed to remove the constructed bedrooms from the garage and agreed to submit proof of removal of the structures to CCLD no later than POC due date.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the water temperature was measured in the resident bathrooms to be between 129.3 and 133.3 degrees Fahrenheit which poses an immediate health risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
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Administrator agreed to submit proof of an appropriate water temperature in the resident bathrooms to CCLD no later than POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2025


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