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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200993
Report Date: 08/21/2025
Date Signed: 08/21/2025 04:15:27 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-20250502150704
FACILITY NAME:DESIRED PEACE HOME CARE 2FACILITY NUMBER:
079200993
ADMINISTRATOR:LAM, PAUL K.FACILITY TYPE:
740
ADDRESS:2024 SAGE SPARROW STREETTELEPHONE:
(510) 759-8889
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 5DATE:
08/21/2025
UNANNOUNCEDTIME BEGAN:
02:52 PM
MET WITH:Ana Morales, CaregiverTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Licensee does not ensure that incidents are reported to authorized representatives.
INVESTIGATION FINDINGS:
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On 08/21/2025 at 2:52PM, Licensing Program Analyst (LPA), T. Syess-Gibson arrived unannounced to deliver complaint findings for the allegation above. LPA met with Ana Morales, Caregiver, and explained the reason for the visit. Ana contacted Paul Lam, Administrator, via telephone regarding visit. Paul arrived at 3:50PM.

During the course of the investigation the LPA interviewed staff, residents, hospice case manager, reviewed and obtained records.

Allegation:
Licensee does not ensure that incidents are reported to authorized representatives.
During interview and record review, it was revealed that Licensee failed to report incidents to CCLD.


Continue 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 6
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-20250502150704

FACILITY NAME:DESIRED PEACE HOME CARE 2FACILITY NUMBER:
079200993
ADMINISTRATOR:LAM, PAUL K.FACILITY TYPE:
740
ADDRESS:2024 SAGE SPARROW STREETTELEPHONE:
(510) 759-8889
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 5DATE:
08/21/2025
UNANNOUNCEDTIME BEGAN:
02:52 PM
MET WITH:Ana Morales, CaregiverTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Licensee does not ensure facility has night staff to care and supervise residents
Licensee does not provide adequate supervision resulting in neglect and lack of care to residents.
Licensee does not ensure that incontinent residents are kept clean and dry.
Licensee does not follow hospice care plan
Licensee does not ensure residents are repositioned which results in developing wounds.
Staff will retaliate against residents if they report to Ombudsman and CCLD
INVESTIGATION FINDINGS:
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On 08/21/2025 at 2:52PM, Licensing Program Analyst (LPA), T. Syess-Gibson arrived unannounced to deliver complaint findings for the allegations above. LPA met with Ana Morales, Caregiver, and explained the reason for the visit. Ana contacted Paul Lam, Administrator, via telephone regarding visit. Paul arrived at 3:50PM.

During the course of the investigation the LPA interviewed staff, residents, hospice case manager, reviewed and obtained records.

Allegation:
Licensee does not ensure facility has night staff to care and supervise residents
During interviews with residents, staff and record review, record review revealed the facility have night staff scheduled. During interview with staff, it was revealed there is one staff member scheduled monthly on the night shift. During interview with residents, it was revealed that when residents used their call button at night, staff come into their rooms to assist with their needs.

(Continue 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: 2 of 6
Control Number 15-AS-20250502150704
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 2
FACILITY NUMBER: 079200993
VISIT DATE: 08/21/2025
NARRATIVE
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Licensee does not provide adequate supervision resulting in neglect and lack of care to residents.
During Interviews with staff it was revealed, licensee has adequate supervision to care for the residents. During interviews with residents, it was revealed that their needs are met, and staff respond to call buttons timely. During record review, it revealed the facility has two (2) staff members, house manager on AM shift and one (1) staff for the night shift.

Licensee does not ensure that incontinent residents are kept clean and dry.


During interviews with staff, it was revealed that R1 was the only incontinent resident and is changed after each meal and between meals throughout the day. During record review, it was revealed that facility has a changing schedule for incontinent resident.

Licensee does not follow hospice care plan.


During interviews with staff and hospice social worker, it was revealed staff were trained by the agency on handling R1’s daily needs. During record review it was revealed that R1 is a two person assistance,facility assist hospice assistant and facility does follow R1’s hospice care plan.

Licensee does not ensure residents are repositioned which results in developing wounds.


During interview with staff, hospice case manager, it was revealed that R1 is the only resident who is bedridden and on hospice that requires repositioning. During record review revealed, R1 is re positioned every four hours daily.

Staff will retaliate against residents if they report to Ombudsman and CCLD.


During interviews with residents, it was revealed that residents don’t feel they will be retaliated against if they were to report to the ombudsman or CCLD. R2 and R3 also stated during interview, that they both have a great relationship with staff and have never had any conversations with any of the staff regarding reporting to any agency.

Continue on LIC9099C

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: 3 of 6
Control Number 15-AS-20250502150704
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 2
FACILITY NUMBER: 079200993
VISIT DATE: 08/21/2025
NARRATIVE
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Continued from LIC9099C


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: 4 of 6
Control Number 15-AS-20250502150704
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 2
FACILITY NUMBER: 079200993
VISIT DATE: 08/21/2025
NARRATIVE
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Continued from LIC9099


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 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 6
Control Number 15-AS-20250502150704
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 2
FACILITY NUMBER: 079200993
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
87211(a)
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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: This requirement is not met as evidence by:

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Administrator agreed to read 87211(a) and send a self certifying email to CCLD by POC date.
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Based on interviews and record review, licensee did not comply with section cited above by not submitting incident reports and hospice notification to CCLD which poses a potential health and safety 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.
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: 6 of 6