079200993-9-21-2021-15-AS-LIBO-C73SZS-20210921141936

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200993
Report Date: 09/21/2021
Date Signed: 09/21/2021 02:21:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	DESIRED PEACE HOME CARE 2		FACILITY NUMBER:	079200993
ADMINISTRATOR:	LAM, PAUL K.		FACILITY TYPE:	740
ADDRESS:	2024 SAGE SPARROW STREET		TELEPHONE:	(510) 759-8889
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	6	CENSUS: 6	DATE:	09/21/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Paul Lam		TIME COMPLETED:	02:40 PM

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	On 09/21/2021 at 12:50 PM, Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and explained the purpose of the visit with Paul Lam. LPA observed 6 residents during the visit. Facility has a completed mitigation plan. LPA inspected the facility inside and outside. Infection control designated leader is the Administrator. There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at least 72 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational. Water temperature was checked 108.8 degrees Fahrenheit. Fire extinguisher has a check tag September 2021. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DESIRED PEACE HOME CARE 2	FACILITY NUMBER: 079200993
	VISIT DATE: 09/21/2021

NARRATIVE

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LPA observed the following:

· Facility has NOT conducted staff training on infection prevention, symptoms, transmission and PPE use. Type B violation was cited. Proof of correction need to be submitted on or before 10/08/2021.

· Facility DO NOT have adequate 30-day supply of PPE (Administrator need N95). Proof of correction needed by 9/24/2021. Technical assistance provided.

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.

Deficiencies and plan and proof of corrections were discussed with Paul Lam.

Exit interview conducted and a copy of this report provided. Appeal rights was given.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DESIRED PEACE HOME CARE 2	FACILITY NUMBER: 079200993
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(d)(5)

Personnel Requirements - General

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview , the licensee did not comply with the facility has NOT conducted staff training on infection prevention, symptoms, transmission and PPE use in which poses/posed a potential health, safety risk to persons in care.
	POC Due Date: 10/08/2021
	Plan of Correction
1 2 3 4	Administrator will train all staff on infection prevention, symptoms, transmission and PPE use, proof of training is needs to be submitted to LPA via email on POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

LIC809 (FAS) - (06/04)

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