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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200993
Report Date: 09/17/2024
Date Signed: 09/17/2024 02:15:45 PM


Document Has Been Signed on 09/17/2024 02:15 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 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:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:18 AM
MET WITH:Alejandra Martinez, Caregiver TIME COMPLETED:
02:31 PM
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On 09/17/2024 at 11:18 AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Caregiver , Irma Martinez explained purpose of visit. Irma spoke with Administrator, Paul Lam via telephone, and explained the purpose of the visit. The Administrator arrived at 11:46AM LPA observed via CCLD website that Administrator Certificate is currently in pending status. Facility has census of 5. The facility’s fire clearance was approved for six (6) non-ambulatory residents.


LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of six (6) bedrooms and three (3) bathrooms. LPA did not observe any bodies of water. A comfortable temperature is maintained at 77 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 110.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non skid mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 08/19/2024. Emergency Disaster Plan was last posted on 08/21/2024. First aid kit was observed to be complete. Fire drill was last conducted on 09/01/2024.

Continued LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
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 2


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 2
FACILITY NUMBER: 079200993
VISIT DATE: 09/17/2024
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Continued from LIC809.

LPA reviewed all five (5) resident records and four (4) staff records , and they were current and complete. LPA also reviewed a sample of medications during visit.

LPA requested updated copies of the following documents to be submitted to CCLD by 09/24/2024.

· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan
· Liability Insurance
· Current Administrator’s Certificate


No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2