079200993-5-9-2023-15-AS-HHUL-CRWVJT-20230517162917

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200993
Report Date: 05/09/2023
Date Signed: 05/09/2023 05:28:41 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/10/2022 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20220810091750

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: 4	DATE:	05/09/2023
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Paul Lam, Administrator		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Residents are restrained in beds with rails.

INVESTIGATION FINDINGS:

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On 5/9/2023 at around 2:30PM, Licensing Program Analyst (LPA) L Ibo arrived unannounced to conduct an unannounced complaint visit and deliver the investigation finding. LPA met staff S2 and S3, LPA called Administrator Paul Lam to informed him the purpose of the visit.

Allegation: Residents are restrained in beds with rails.
Based on LPA’s observation, staff interview and records review. Two out of 4 residents which was not on hospice care was observed to using full bed rails.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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 4

Control Number 15-AS-20220810091750

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/12/2023 Section Cited CCR 87608(a)(5)(B)	1 2 3 4 5 6 7	(B) 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 evidenced by:	1 2 3 4 5 6 7	Administrator has agreed to remove full bed rails for the two residents and submit picture proof to CCLD by POC date.
	8 9 10 11 12 13 14	Based on observation, the licensee did not comply with the section cited above by having full bed rails for residents who are not on hospice care which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14	During LPA's visit R4's bed rail was changed to half rail.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/10/2022 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20220810091750

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: 4	DATE:	05/09/2023
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Paul Lam, Administrator		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Resident's medications are being improperly managed.
Residents are put to bed early.
Residents are left alone in the facility with no supervision.
Facility is not providing resident incontinence care.
Lack of supervision sustaining injury

INVESTIGATION FINDINGS:

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On 5/9/2023 at around 2:30PM, Licensing Program Analyst (LPA) L Ibo arrived unannounced to conduct an unannounced complaint visit and deliver the investigation finding. LPA met staff S2 and S3, LPA called Administrator Paul Lam to informed him the purpose of the visit.

Resident's medications are being improperly managed.

Based on records review, medication administration records (MAR) revealed that staff gave residents medication according to physician’s order. Residents MAR revealed there was no miss medications and discontinued medication was stopped per doctor’s order.

...Continue to LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20220810091750

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/09/2023

NARRATIVE

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Allegation: Residents are put to bed early.
Based staff interview and residents’ interview, the residents do not have specific bedtime, according to the staff, R2 goes to bed around 7:00pm-8:00pm, R3’s bedtime was around 6:00pm-7:00PM, R4’s bedtime is around 7:00PM, and R5’s bedtime varies between 7:00PM-9:00PM. Based on residents interview, residents stated that they can go to bed whatever time they want and staff are not forcing them to be in bed early.

Allegation: Residents are left alone in the facility with no supervision.

Based on records review and interview with staff and residents, it was revealed that there is one awake night staff on duty. Night shift starts at around 6:00PM to provide care and supervision to residents in care.

Allegation: Facility is not providing resident incontinence care.

During the course of interview with residents and staff. The residents stated that staff provide incontinence care at least 2-3x per shift. Staff stated they change the residence at least every 2-3hours per shift.

Allegation: Lack of supervision sustaining injury

LPA attempted to conduct interview with resident (R1), however R1 was not available for interview. Administrator stated resident (R1) had un-witnessed fall while resident was eating at the dining area. The staff assessed the resident (R1) when resident was found on the floor, based on staff interview there were no injury noted, hospice agency was informed about the incident. Based on records review for resident’s (R1), the care plan did not indicate that R1 was one-on-one care.

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. A copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC9099 (FAS) - (06/04)

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