079200993-2-2-2024-15-AS-YFLS-D2WVHM-20240229152718

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200993
Report Date: 02/02/2024
Date Signed: 02/02/2024 12:06:05 PM

Unsubstantiated

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
11/29/2023 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20231129143050

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:	02/02/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Paul Lam, Administrator and Rine Javier, Care Staff		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Resident sustained injuries due to lack of care from staff

INVESTIGATION FINDINGS:

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On 2/02/2024 at 11:00 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver findings in regard to the allegation above. LPA met with Administrator, Paul Lam (ADM) and informed him the reason for visit. ADM had to leave during the visit and gave permission for care staff to sign the report. LPA reviewed findings with ADM prior to him leaving.

During the course of the investigation LPA inspected the resdient's bedrooms, reviewed R1's file, staff schedule, overnight log and interviewed S1.

R1 was admitted to the facility on 11/23/23 from a rehabilitation facility. There was no documentation in R1’s admitting paperwork that he was a fall risk. On the morning of 11/24/23 R1 was found on the floor of his bedroom next to his bed by care staff and a therapist. 911 was called and R1 was sent to Kaiser emergency department for further evaluation. It was discovered that R1 had pneumonia and would remain in the hospital for treatment.
***report continues on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20231129143050

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: 02/02/2024

NARRATIVE

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***report continues from LIC9099***

R1 returned to the facility on 11/28/23. Given R1’s fall risk and nighttime restlessness the facility put in place an overnight staff to monitor R1. Previously the live-in care staff monitored the residents during the overnight shift. LPA observed that there are no cameras in the residents bedrooms.

LPA reviewed the overnight log. Overnight staff documented several occasions where R1 was restless or was trying to get out of bed. Staff redirect R1 to lay down and stay with him until he falls back asleep.

S1 stated that R1 is currently on hospice. R1’s medications were also recently adjusted, and he is less restless during the night, however overnight staff remain in place.

This agency has investigated the complaint alleging resident sustained injuries due to lack of care from staff. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

LIC9099 (FAS) - (06/04)

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