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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530026
Report Date: 09/03/2025
Date Signed: 09/03/2025 10:51:47 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/26/2025 and conducted by Evaluator Raquel Hernandez
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250826141156
FACILITY NAME:PRINCE OF PEACE CORPORATIONFACILITY NUMBER:
335530026
ADMINISTRATOR:OLADIMEJI, OLUWATOYINFACILITY TYPE:
735
ADDRESS:12658 DUTCH COURTTELEPHONE:
(678) 622-6131
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:4CENSUS: 2DATE:
09/03/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Oluwatoyin OladimejiTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Facility staff are not dispensing medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit for the purpose of delivering findings for the above allegations. LPA met with Administrator Oluwatoyin Oladimeji and explained today's visit.

For the allegation, Facility staff are not dispensing medication as prescribed.

LPA observed medication for Client #1 (C1) was not documented on Medication Administration Record (MAR). Administrator stated medication was given but not documented in MAR.




Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
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 5
Control Number 56-AS-20250826141156
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PRINCE OF PEACE CORPORATION
FACILITY NUMBER: 335530026
VISIT DATE: 09/03/2025
NARRATIVE
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Based on the evidence gathered during today’s investigation, the one (1) allegation listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegation are valid because the preponderance of evidence the standard has been met.

During today’s visit, a deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) and LIC9099D was discussed and provided to Administrator Oluwatoyin Oladimeji along with a copy of the appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/26/2025 and conducted by Evaluator Raquel Hernandez
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250826141156

FACILITY NAME:PRINCE OF PEACE CORPORATIONFACILITY NUMBER:
335530026
ADMINISTRATOR:OLADIMEJI, OLUWATOYINFACILITY TYPE:
735
ADDRESS:12658 DUTCH COURTTELEPHONE:
(678) 622-6131
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY:4CENSUS: 2DATE:
09/03/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Oluwatoyin OladimejiTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Facility staff do not keep facility at a comfortable temperature
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit for the purpose of delivering findings for the above allegations. LPA met with Administrator Oluwatoyin Oladimeji and explained today's visit.

For the allegation, Facility staff do not keep facility at a comfortable temperature.

LPA observed facility temperature to be at 74 degrees farenheit during visit. Administrator stated facility air conditioner is kept on auto cycle throughout the day.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
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 5
Control Number 56-AS-20250826141156
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PRINCE OF PEACE CORPORATION
FACILITY NUMBER: 335530026
VISIT DATE: 09/03/2025
NARRATIVE
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Based on the evidence gathered during today’s investigation, the allegation listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted and this report (LIC9099A) along with other forms were discussed and provided to Administrator Oluwatoyin Oladimeji.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20250826141156
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PRINCE OF PEACE CORPORATION
FACILITY NUMBER: 335530026
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/04/2025
Section Cited
CCR
80075(5)(B)
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80075 Health Related Services (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for... (B) Once ordered by the physician the medication is given according to the physician's directions.
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Licensee stated to submit staff training to LPA Hernandez by Plan of Correction (POC) due date.
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Based on observation and record review, the licensee did not comply with the section cited above by not enusring Medication Administration Record (MAR) for Client #1 (C1) was documented properly which poses an immediate health, safety or personal rights risk to 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: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5