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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609929
Report Date: 03/03/2022
Date Signed: 03/03/2022 12:56:46 PM



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
04/15/2021 and conducted by Evaluator Joann Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20210415142327
FACILITY NAME:A PEACE OF HOMEFACILITY NUMBER:
567609929
ADMINISTRATOR:PEREY, HERBERT M.FACILITY TYPE:
740
ADDRESS:1227 MIKA WAYTELEPHONE:
(805) 278-9620
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY:6CENSUS: 3DATE:
03/03/2022
UNANNOUNCEDTIME BEGAN:
12:16 PM
MET WITH:Herbert PereyTIME COMPLETED:
12:53 PM
ALLEGATION(S):
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Facility is understaffed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a subsequent unannounced complaint investigation visit to deliver final investigation findings. LPA met with Administrator Herbert Perey.

Concerns were that one staff was unable to assist all 4 residents with activities of daily living at the same time. Interviews with staff and residents conducted on 4/23/21 starting at 1:32 pm, 12/2/21 at 3:58 pm and 3/1/22 at 2:58 pm revealed that from staff are working alone from 3:30 pm to 5 pm and from 7 pm to 7:30 am. A review of resident records on 12/2/21 starting at 12:28 pm revealed that resident #1 (R1) has sundowning behaviors, is non-ambulatory, needs assistance with transferring, toileting, dressing, bathing hair care and personal hygiene, needs special observation/night supervision and is confused/disoriented. R2 has wandering and sundowning behaviors, is non-ambulatory, has bowel and bladder impairment, needs assistance with transferring, toileting, dressing, bathing hair care and personal hygiene, needs special observation/night

Continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
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-20210415142327
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 PEACE OF HOME
FACILITY NUMBER: 567609929
VISIT DATE: 03/03/2022
NARRATIVE
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supervision and is confused/disoriented. R3 needs assistance with transferring, toileting, dressing, bathing hair care and personal hygiene, needs special observation/night supervision, is non-ambulatory and is confused/disoriented at times. R4 has wandering and sundowning behaviors, is non-ambulatory, has visual and auditory hallucinations, and is confused/disoriented. A review of staff timecards from 3/1/21 to 4/15/21 on 12/28/21 starting at 1:56 pm revealed that from 7:30 pm to 7:30 am there is only one staff working. Based on the information obtained during the course of the investigation the allegation is deemed substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D):

Exit interview was conducted, today's report was reviewed and emailed to the Administrator

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20210415142327
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 PEACE OF HOME
FACILITY NUMBER: 567609929
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2022
Section Cited
CCR
87411(a)
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87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…The licensing agency may require any facility to provide additional staff whenever it determines through...
This requirement is not met as evidenced by:
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Administrator stated that they will provide an updated LIC500 which reflects additional staffing to meet the residents needs to CCL by 3/11/22.
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Based on interviews and record review, the licensee did not comply with the section cited above as the facility has one caregiver from 7:30 pm to 7:30 am which poses a potential safety and 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.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3