567609929-12-2-2021-29-AS-JROS-C9C5B3-20211202184802

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609929
Report Date: 12/02/2021
Date Signed: 12/02/2021 06:48:20 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	A PEACE OF HOME		FACILITY NUMBER:	567609929
ADMINISTRATOR:	PEREY, HERBERT M.		FACILITY TYPE:	740
ADDRESS:	1227 MIKA WAY		TELEPHONE:	(805) 278-9620
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY:	6	CENSUS: 6	DATE:	12/02/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:54 AM
MET WITH:	Herbert Perey		TIME COMPLETED:	04:16 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced Required - 1 year inspection. LPA met with Administrator Herbert Perey and Assistant Administrator Mischelle Perey. A physical plant tour was conducted to ensure there are no health and safety hazards. The facility is currently fire cleared for 6 non-ambulatory residents of which 2 may be bedridden. The facility was observed to be clean, safe, sanitary, and in good repair. LPA observed one central entry point designated for universal entry screening. Cleaning supplies were observed and infection control practices were discussed. An inspection of the common area, resident rooms and restrooms were conducted. The resident restrooms were observed to be clean and sanitary and in working condition. There is an adequate amount of perishable food. LPA observed fire extinguishers fully charged. Smoke detectors and carbon monoxide detectors were tested and operable. Grab bars were present in the bathrooms. Hygiene items are being provided. Outdoor area toured- passageways are free of obstruction. During facility tour at 11:19 am with Assistant Administrator Mischelle Perey LPA observed hot water temperature at 141.3 degrees F. in resident bathroom. During facility tour at 11:28 am with Assistant Administrator Mischelle Perey LPA observed resident #1 (R1)'s lactulose and lorazepam in the kitchen refrigerator accessible to residents. Assistant Administrator stated that they were unaware that the medications needed to be kept in a locked location. During facility tour starting at 11:32 am with Assistant Administrator Mischelle Perey LPA did not observe a sufficient supply of non-perishable vegetables and fruit as the facility had 2 small cans of potatoes, 1 large can of corn and 2 small cans of applesauce. Continued on 809C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 PEACE OF HOME	FACILITY NUMBER: 567609929
	VISIT DATE: 12/02/2021

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to the Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 PEACE OF HOME	FACILITY NUMBER: 567609929
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (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
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above as the hot water temperature in a resident bathroom read at 141.3 degrees F. which poses an immediate health and safety risk to persons in care.
	POC Due Date: 12/02/2021
	Plan of Correction
1 2 3 4	Administrator turned down water heater temperature during facility visit.

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
1 2 3 4	Based on LPA's observations, the licensee did not comply with the section cited above as R1's medication was observed in the kitchen refrigerator accessible to residents which poses an immediate health risk to persons in care.
	POC Due Date: 12/02/2021
	Plan of Correction
1 2 3 4	Assistant Administrator placed R1's medications in a locked garage refrigerator during facility visit. Administrator stated that they will provide documentation of staff medication training to CCL by 12/13/21.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 PEACE OF HOME	FACILITY NUMBER: 567609929
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(26)

General Food Service Requirements

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations, the licensee did not comply with the section cited above as the facility did not have a one week supply of nonperishable vegetables and fruit which poses a potential health and personal rights risk to persons in care.
	POC Due Date: 12/06/2021
	Plan of Correction
1 2 3 4	Administrator stated that they wll provide documentation of a one week supply of nonperishable vegetables and fruit to CCL by 12/6/21.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

LIC809 (FAS) - (06/04)

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