425850511-4-3-2025-29-AS-KBUY-DG7282-20250428170938

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850511
Report Date: 04/03/2025
Date Signed: 04/03/2025 11:28:47 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/01/2025 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20250401115533

FACILITY NAME:	A PEACEFUL PLACE ON RICE RANCH RD LLC		FACILITY NUMBER:	425850511
ADMINISTRATOR:	CASTRO, ROSA		FACILITY TYPE:	740
ADDRESS:	711 E RICE RANCH RD		TELEPHONE:	(805) 714-0579
CITY:	ORCUTT	STATE: CA	ZIP CODE:	93455
CAPACITY:	6	CENSUS: 6	DATE:	04/03/2025
		UNANNOUNCED	TIME BEGAN:	07:58 AM
MET WITH:	Administrator, Rosa Castro		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff does not ensure expired medications are properly discarded.
Staff does not ensure medication are properly labeled.
Staff does not ensure medication records are properly maintained.
Staff does not ensure food containers are properly labeled.
Staff does not ensure expired food is properly removed from the facility.
Staff does not ensure resident health care needs are being met.
Licensee allows unqualified staff to dispense medications.

INVESTIGATION FINDINGS:

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At 8:00am on 04/03/2025, Licensing Program Analyst (LAP) Jeffries arrived to the facility unannounced to conduct the initial investigation visit to the allegations to this complaint. LPA met with Staff Diane Sanchez (S1), and Staff Luz Diaz-Valencia (S2). Both staff and LPA called Administrator on the phone and left a message to contact or come to the facility. Administrator, Rosa Castro arrived to the facility at 9:00am.
LPA conducted a physical tour of the facility focusing on the kitchen and medication room. LPA took photographs of food, and noted the food to be of good quality and at least 2 days of perishable foods and at least 7 days of non perishable foods. LPA conducted interviews of staff and residents. LPA conducted a sample medication audit, requested and reviewed documentation. LPA issued final findings to all allegations to this complaint.
As to the allegations of, “Staff does not ensure expired medications are properly discarded.” and “Staff does not ensure medications are properly labeled.” It was alleged that, in March of 2025, “old medications in the medication cabinet that were all expired and some bottles that had no labels on them.”
CONTINUED on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

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 3

Control Number 29-AS-20250401115533

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A PEACEFUL PLACE ON RICE RANCH RD LLC	FACILITY NUMBER: 425850511
	VISIT DATE: 04/03/2025

NARRATIVE

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It was discovered through observations, that on 04/03/2025 Administrator and LPA conducted a medication audit and reviewed medications of R1 and R2. LPA noted that medications for R1 were stored in both bottle and bubble pack storage from the pharmacy. R1’s bottled storage was prescribed before his admission to the facility and was still current by the Physicians prescription requirements. The remainder of R1’s medications were stored in bubble pack form from the pharmacy. R2’s medications were stored in bubble pack form from the pharmacy. No irregularities were noted during the medication audit. No expired medication was present, and no medication labels were altered. On 04/03/2025, LPA Jeffries noted that 5 empty bubble packs were set aside as the medication had been administered as prescribed as medication cycle for those bubble packs had been exhausted on this day (04/03/2025) and were placed aside to be discarded. At this time there is not enough evidence to support the allegations of, “Staff does not ensure expired medications are properly discarded.” and “Staff does not ensure medications are properly labeled.” And is unsubstantiated at this time.
As to the allegation of, “Staff does not ensure that medication records are properly maintained.” It was alleged that in March of 2025, that, “residents’ medications not being logged on the MAR sheet each day.” It was discovered through interviews and documentation review that on 04/03/2025, LPA Jeffries conducted an interview with Administrator who stated that medication training and shadow training indicates that staff dispensing medications to sign the Medication Administration Record (MAR) immediately after dispensing medication to Residents. On 04/03/2025, LPA Jeffries noted in the medication records audit that there were no abnormalities or missed medication logs observed. LPA Jeffries noted that MAR and Centrally Stored Medication Records (CSMR) are also free of error and free of discrepancies. At this time there is not enough evidence to support the allegation of, “Staff does not ensure that medication records are properly maintained.” and is unsubstantiated at this time.
As to the allegation of, “Staff does not ensure food containers are properly labeled.” and “Staff does not ensure expired food is properly removed from the facility.” It was alleged that, “old food containers without dated labels on them in the fridge.” It was discovered through observation and interviews that on 04/03/2025 LPA Jeffries conducted observational investigation as to the content of all food stored and prepared at this facility and found no improperly stored food, no food with degradation of quality, no expired foods, or stored food at a damaging temperature. On 04/03/2025, LPA conducted interviews of S1 and S2 both indicated that the food served at the facility is always of high quality and if they need to they can discard spoiled, or damaged food as needed.
CONTINUED on LIC9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20250401115533

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A PEACEFUL PLACE ON RICE RANCH RD LLC	FACILITY NUMBER: 425850511
	VISIT DATE: 04/03/2025

NARRATIVE

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On 04/03/2025, LPA Jeffries conducted interview with Residents 1-4.(R1, R2, R3, and R4) All residents had no complaints of the quality of food and have never been served spoiled or damaged foods. At this time there is not enough evidence to support the allegations of “Staff does not ensure food containers are properly labeled.” and “Staff does not ensure expired food is properly removed from the facility.” and is unsubstantiated at this time.
As to the allegation of, “Staff does not ensure resident health care needs are being met.” It was alleged that in March of 2025, “one of the residents has shingles” and the licensee failed to get the resident proper treatment for health condition. It was discovered through interviews and documentation that on 04/03/2024, R2 has visited their primary care physician on 02/27/2025. 03/04/2025 and 03/27/2025 to specifically address the condition alleged in this allegation. On 04/03/2025, LPA Jeffries conducted an interview with Administrator who stated that R1 has visited their physician three times for assessment and treatment to the condition listed in this complaint allegation. On 04/03/2025 LPA reviewed R1’s full file documentation on medical documentation verifying that R1 has been seen by a medical professional on 02/27/2025. 03/04/2025 and 03/27/2025 and has had their health care needs being met. On 04/03/2025, LPA Jeffries conducted and interview with R2, who stated they feel safe in this facility, and they (facility) have helped with all needs medical and other. At this time there in not enough evidence to support the allegation of. “Staff does not ensure resident health care needs are being met.” And is unsubstantial at this time.
As to the allegation of, “Licensee allows unqualified staff to dispense medications.” It was alleged that in March of 2025 that. “Care staff are not trained on dispensing medications to residents.” It was discovered through documentation and interviews that on 04/03/2025, LPA Jeffries conducted interviews with S1 and S2 who both stated that they have had several hours of medication administration training and shadowing. An interview on 04/03/2025 LPA conducted an interview with Administrator who stated that all staff get medication administration training but has S1 and S2 are the main medication technicians for dispensing medication at this facility. On 04/03/2025 LPA reviewed and collected documentation indicating that S1 and S2 have had required medication administration training to assist residents with daily medications. At this time there is not enough evidence to support the allegation of, “Licensee allows unqualified staff to dispense medications”. And is unsubstantiated at this time.

Exit interview, report read, and report provided

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025

LIC9099 (FAS) - (06/04)

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