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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603875
Report Date: 08/19/2026
Date Signed: 08/19/2026 01:59:01 PM

Document Has Been Signed on 08/19/2026 01:59 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PEACEFUL STAY LLC.FACILITY NUMBER:
198603875
ADMINISTRATOR/
DIRECTOR:		MCGEE, OZIOMACHUKWUFACILITY TYPE:
740
ADDRESS:800 E 82ND STTELEPHONE:
(310) 963-7288
CITY:LOS ANGELESSTATE: CAZIP CODE:
90001
CAPACITY: 6CENSUS: 3DATE:
08/19/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:24 AM
MET WITH:Betania NajarroTIME VISIT/
INSPECTION COMPLETED:
02:11 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with caregiver Betania Najarro and explained reason for visit. Licensee Tyrone Mcghee was notified by telephone.

Facility is licensed to serve six (6) residents age 60 and over of which 3 may be non-ambulatory. Bedrooms #1 and #4 approved for non-ambulatory residents. Hospice waiver approved for 3 residents. RCFE/Dementia. The facility is in a residential area. A tour of the facility included the living room/dining area, kitchen with washer and dryer, 3 resident bedrooms, 1 resident bathroom, one staff room with bathroom, and outside shaded area for residents.

LPA toured the facility and observed the following: License for facility was not posted anywhere in the home TV issued. LPA observed required PUB 475 posting but not correct size TV issued. Each resident bedroom has the required furniture and bedding. LPA observed extra clean linen and towels in storage area. The smoke /carbon monoxide detectors were observed throughout the facility and are properly operating. The facility has one (1) fire extinguisher in living room. A bottle of Awesome cleaning bleach spray was observed to be accessible to residents under bathroom sink at time of visit. The hot water temperature in the resident’s bathroom was measured at 124.4 not within the required range of 105-120 F. Freezers are maintained at a temperature of 0 degree F and the refrigerators at a maximum of 40 degrees F. Facility was observed to have a sufficient supply of 2 days perishable & 7 days non-perishable foods. LPA observed injectable medication not in lock box accessible to residents in refrigerator. There are no firearms or weapons stored at the facility. The facility does not have a swimming pool or bodies of water on the premises There is a shaded area for the residents outside with a table, but no chairs TV issued. Passageways and exits are free of obstruction. SEE LIC 809C

David Sicairos
Christian Gutierrez
DATE: 08/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2026
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 13
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 13
Document Has Been Signed on 08/19/2026 01:59 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/19/2026 at 12:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PEACEFUL STAY LLC.
FACILITY NUMBER: 198603875

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in bathroom had a reading of 124.4 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2026
Plan of Correction
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Water is to be lowered to the required water range and a picture is to be sent to LPA by POC due date. Administrator will create a water log for one week and send LPA log by 08/26/26.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in Awesome cleaner with bleach spray bottle was observed under bathroom sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2026
Plan of Correction
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Caregiver removed cleaner at time of visit. Administrator will conduct training on section 87309(a) with staff and send log with staff signatures to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2026


LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 08/19/2026 01:59 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/19/2026 at 12:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PEACEFUL STAY LLC.
FACILITY NUMBER: 198603875

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in two (2) out of three (3) staff did not have training in file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2026
Plan of Correction
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Administrator will send LPA proof of CPR/First Aid training for staff and insure at least one staff who is trained is on duty at all times.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in R3 did not have two daily required medications at time of vist which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2026
Plan of Correction
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Administrator wil fill medication and provide LPA pictures of medication.
R3 -Atrovastatin 80 MG 1x night and Amlodipine 25 MG daily.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2026


LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 08/19/2026 01:59 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/19/2026 at 12:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PEACEFUL STAY LLC.
FACILITY NUMBER: 198603875

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above LPA observed injectable medication unlocked in refrigerator accessible to other residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2026
Plan of Correction
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Administrator will purchase lock box for medication that needs to be stored in refrigerator and send LPA picture by POC due date,
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2026


LIC809 (FAS) - (06/04)
Page: 5 of 13
Document Has Been Signed on 08/19/2026 01:59 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/19/2026 at 12:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PEACEFUL STAY LLC.
FACILITY NUMBER: 198603875

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above infection control plan was not available at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2026
Plan of Correction
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Administrator will email infection control plan to LPA by POC due date.
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above liability insurance was not available at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2026
Plan of Correction
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2
3
4
Administrator will email LPA insurance by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2026


LIC809 (FAS) - (06/04)
Page: 6 of 13
Document Has Been Signed on 08/19/2026 01:59 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/19/2026 at 12:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PEACEFUL STAY LLC.
FACILITY NUMBER: 198603875

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in three (3) out of three (3) staff files were not complete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2026
Plan of Correction
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2
3
4
Admin- LIC 501 job application with resume,Lic 503 health screening with TB and employee rights.
S1-LIC 503 health screening with TB and employee rights.
S2- LIC 503 health screening with TB and employee rights.
Type B
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in two (2) out of two (2) staff did not have required training in files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2026
Plan of Correction
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2
3
4
Administrator will provide all required training to LPA by POC due date. Please refer to training required for RCFE for all staff.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2026


LIC809 (FAS) - (06/04)
Page: 7 of 13
Document Has Been Signed on 08/19/2026 01:59 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/19/2026 at 12:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PEACEFUL STAY LLC.
FACILITY NUMBER: 198603875

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in two (2) out of three (3) residents did not have a list of medications with dosages in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2026
Plan of Correction
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2
3
4
Administrator will obtain a current centrally stored medication list for all residents and send to LPA by POC due date. Administrator will clarify R2 medication once list is provided. (Atorvastin, Ferrous Sulfate,Clonidine)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in three (3) out of three (3) residents were missing required documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2026
Plan of Correction
1
2
3
4
R1-Physicians report LIC 602 with TB, LIC 627 consent form, LIC 601 ID/emergency form, LIC 603 pre appraisal,and LIC 613 resident rights.
R2-LIC 627 consent forms, LIC 603 pre appraisal,and LIC 613 resident rights.
R3-Physicians report LIC 602 with TB, LIC 627 consent form, LIC 601 ID/emergency form, LIC 603 pre appraisal,and LIC 613 resident rights.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2026


LIC809 (FAS) - (06/04)
Page: 8 of 13
Document Has Been Signed on 08/19/2026 01:59 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 08/19/2026 at 12:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PEACEFUL STAY LLC.
FACILITY NUMBER: 198603875

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in facility did not have a complete emergency disater plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2026
Plan of Correction
1
2
3
4
Administrator will send completed 610 D to LPA by POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above facility could not provide emergency drills at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2026
Plan of Correction
1
2
3
4
Administrator will send LPA drills by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2026


LIC809 (FAS) - (06/04)
Page: 9 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PEACEFUL STAY LLC.
FACILITY NUMBER: 198603875
VISIT DATE: 08/19/2026
NARRATIVE
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3
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5
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32
LPA reviewed three (3) staff files and observed the following missing: Admin- LIC 501 job application with resume, LIC 503 health screening with TB and employee rights. S1-LIC 503 health screening with TB and employee rights, S2- LIC 503 health screening with TB and employee rights. LPA reviewed three (3) resident files and observed the following: missing: R1-Physicians report LIC 602 with TB, LIC 627 consent form, LIC 601 ID/emergency form, LIC 603 pre appraisal, and LIC 613 resident rights. R2-LIC 627 consent forms, LIC 603 pre appraisal, and LIC 613 resident rights. R3-Physicians report LIC 602 with TB, LIC 627 consent form, LIC 601 ID/emergency form, LIC 603 pre appraisal, and LIC 613 resident rights. LPA also observed two staff missing CPR/First Aid certificates and all required training needed before employment.

LPA requested a copy of the following missing documents to be sent liability insurance, infection control plan, emergency disaster plan, and last drills conducted at facility. LPA reviewed medication for three (3) residents and observed discrepancies/deficiencies. Two residents were missing a centrally stored medication list. Medication are stored in locked file cabinet in living room. MAR log is used.

Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Betania Najarro.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2026
LIC809 (FAS) - (06/04)
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