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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200739
Report Date: 09/09/2026
Date Signed: 09/09/2026 03:09:03 PM

Document Has Been Signed on 09/09/2026 03:09 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:DESIRED PEACE HOME CAREFACILITY NUMBER:
079200739
ADMINISTRATOR/
DIRECTOR:		LAM, PAUL, KFACILITY TYPE:
740
ADDRESS:2181 WAYNE DRTELEPHONE:
(510) 759-8889
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 6DATE:
09/09/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:35 AM
MET WITH:Jean Tancioco, Caregiver TIME VISIT/
INSPECTION COMPLETED:
03:27 PM
NARRATIVE
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On 09/09/2026 at 10:35AM, Licensing Program Analysts (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Jean Tancioco, Caregiver, LPA explained the purpose of visit. The Administrator arrived at approximately 10:55AM and LPA explained the purpose of visit. Facility has census of 6. The facility’s fire clearance was approved for six (6) non-ambulatory residents.

LPA toured the facility with Administrator Paul Lam including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of seven (7) bedrooms, three (3) bathrooms with One (1) bedroom being occupied by staff. All outdoor and indoor passageways are kept free of obstruction. LPAs did not observe any bodies of water. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the resident’s shared bathroom was measured at 113.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and skid mats. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 08/20/2026. Emergency Disaster Plan was last posted on 06/27/2026. First aid kit was observed to be complete. Fire drill was last conducted on 09/01/2026.

Continued LIC809C.

Harpreet Humpal
Tonica Syess-Gibson
DATE: 09/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2026
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.

LIC809 (FAS) - (09/23)
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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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DESIRED PEACE HOME CARE
FACILITY NUMBER: 079200739
VISIT DATE: 09/09/2026
NARRATIVE
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Continued from LIC809

LPA attempted to review four (4) staff records, LPA observed S3, S4 are not fingerprint cleared/associated to facility. LPA also observed S4’s file was not at the facility during inspection. LPA reviewed four (4) residents records, and they were all current and complete.

LPA requested updated copies of the following documents to be submitted to CCLD by 09/16/2026.

  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan
  • Liability Insurance

Continue on LIC809C….

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Tonica Syess-Gibson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2026
LIC809 (FAS) - (06/04)
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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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: DESIRED PEACE HOME CARE
FACILITY NUMBER: 079200739
VISIT DATE: 09/09/2026
NARRATIVE
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Continued from LIC809C...


THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

  • At 11:18AM, LPA observed facility did not have 7 days of nonperishable foods and 2 days of perishables.
  • At 12:07PM, LPA observed S3, S4 are not fingerprint cleared/associated to facility.
  • At 12:11PM, LPA observed S4 file was not at the facility for licensing to review.
  • At 1:12 PM, LPA observed that R2 multivitamins and heartburn & gas tablets are missing doctor's order, and multivitamins are not listed on the Medication Administration Record (MAR).

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.


***a civil penalty of $1000.00 will be assessed today for S3, S4 fingerprint clearance***

Exit interview conducted with Paul Lam. Appeal Rights and a copy of this report were provided.

NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Tonica Syess-Gibson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/09/2026 03:09 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 09/09/2026 at 02:33 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DESIRED PEACE HOME CARE
FACILITY NUMBER: 079200739

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/11/2026
Section Cited
CCR
87555(b)(26)

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(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
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Licensee agreed to purchase a variety of foods and submit photos to CCLD by POC date.
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Based on observation, the licensee did not comply with the section cited above in having a 7-day supply of non-perishables and 2-day perishable foods which poses a potential health, safety or personal rights risk to persons in care.
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Type B
09/18/2026
Section Cited
CCR87412(a)

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(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidence by:
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Licensee agreed to read regulation 87412,create personnel file fro S4 and send CCL a self-certifying email by POC date.
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Based on record review and interview, licensee did not comply with the section above by not having a personnel file for S4 which poses a potential health and safter risk to the 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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Tonica Syess-Gibson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2026


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Document Has Been Signed on 09/09/2026 03:09 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 09/09/2026 at 02:39 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DESIRED PEACE HOME CARE
FACILITY NUMBER: 079200739

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2026
Section Cited
CCR
87355(e)(2)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2)Obtain a California clearance or a criminal record exemption as required by the Department or..This requirement is not met as evidence by:
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Licensee has agreed to obtain fingerprint clearance for the two staff prior to the staff returning to work. Licensee will submit a written plan to CCLD by POC date.
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Based on record review, licensee did not comply with the section cited above by not having S3 and S4 fingerprint cleared which poses an immediate health and safety risk to the persons in care.
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Civil penalty of $1000 is being assessed.

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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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Tonica Syess-Gibson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/09/2026 03:09 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 09/09/2026 at 02:53 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DESIRED PEACE HOME CARE
FACILITY NUMBER: 079200739

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2026
Section Cited
CCR
87465(a)(4)

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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
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Licensee has agreed to obtain doctor's order for R2's daily vitamins and heart burn & gas tablets and submit the document to CCLD by POC date. Additionally, facility will update R2's MAR for future reviews.
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Based on observation and record review, the licensee did not comply with the section cited above by not having a doctor's order for R2's flaxseed oil 1000mg, extra strength heartburn & gas (750 mg calcium carbonate/antiacid, 80 mg simethicone/anti-gas), calcium 600mg and fish oil 2400mg 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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Tonica Syess-Gibson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2026


LIC809 (FAS) - (06/04)
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