567609929-3-23-2023-29-AS-JAPL-CQ8UGU-20230324153455

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609929
Report Date: 03/23/2023
Date Signed: 03/23/2023 07:52:00 PM

Substantiated

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
10/25/2022 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20221025102303

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: 5	DATE:	03/23/2023
		UNANNOUNCED	TIME BEGAN:	06:19 PM
MET WITH:	Herbert Perey		TIME COMPLETED:	08:20 PM

ALLEGATION(S):

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Staff failed to seek timely medical treatment for Resident #1 (R1)

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascecncio conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA Ascencio met with Administrator Herbert Perey and explained the reason for the visit.

On 10/25/2022, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that staff neglected to seek timely medical attention for Resident #1 (R1) after R1 was found with multiple bruises, unable to get out of bed or walk, and later diagnosed with a fractured hip. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Douglas Real.

On 10/26/2022, between 1:52pm and 3:35pm, Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced initial complaint visit.
Continued on LIC 9099 - C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

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 6

Control Number 29-AS-20221025102303

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: 03/23/2023

NARRATIVE

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LPA Lopez initially met with facility staff who contacted Administrator Herbert Perey and advised him of the visit. The Administrator arrived shortly after the visit began. The LPA conducted an entrance interview explaining the reason for the visit. Beginning at 1:58pm, the LPA conducted a physical plant tour with staff and reviewed facility records. Copies of pertinent records were obtained. The LPA determined further investigation was needed and informed the Administrator that the Community Care Licensing Division (CCLD) Investigations Branch (IB) Investigator Douglas Real was assigned to complete the investigation.

Investigator Real conducted interviews on 11/16/2022 with the Licensee/Administrator and staff; on 12/23/2022, with R1’s resident representative; on 12/29/2022, with resident and staff; on 01/06/2023, with residents and staff; on 01/30/2023, with staff; on 01/31/2023, with R1’s resident representative; and on 02/02/2023, with staff. Investigator Real attempted to speak with the complainant on three (3) different occasions, with no response. In addition, the investigator reviewed St. John’s Regional Medical Center medical records and facility file documents related to R1.

A review of R1’s hospital medical records, revealed R1 was admitted to St. John’s Regional Medical Center on 10/23/2022 due to left hip pain. R1 was found to have a left femur neck fracture along with a urinary tract infection and dysphagia (trouble swallowing). R1 was noted as having numerous other health conditions including a history of atrial fibrillation, dementia, Parkinson’s disease, hypertension, and hyperlipidemia and R1’s health was declining. R1’s resident representative decided to transition R1 to hospice for comfort care and R1 passed away in the hospital on 11/02/2022. No abuse or neglect concerns were noted in the medical records.

The investigation revealed the facility staff discovered a significant change in R1’s condition on the morning of 10/23/2022. R1 was unable to get up and walk on their own which was unusual as R1 ambulated on their own with assistance as their baseline, in addition, staff found bruising on R1’s hip, leg, and forearm which also had a cut. These injuries were discovered around 8:00am. Due to R1’s diagnosis of dementia R1 was unable to express how they sustained the injuries or the extent of their injuries and pain. At 1:00 p.m., R1’s resident representative noticed R1 was in pain and unable to walk which prompted them to take R1 to the hospital were R1 was diagnosed with a fractured left femur.

Continued on LIC 9099 - C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 29-AS-20221025102303

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: 03/23/2023

NARRATIVE

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Multiple factors, including R1’s inability to express how the injuries occurred, the severity of the injuries or lack thereof, of any internal injuries or pain, along with the existence of multiple bruises and R1’s inability to walk, should have prompted the facility to seek timely medical attention, which they did not. The Department’s information and evidence obtained during the investigation sufficiently supports the allegation; therefore, the allegation “Facility staff failed to seek timely medical treatment for Resident #1 (R1)” is deemed Substantiated at this time.

A $500 immediate civil penalty is assessed today. The Administrator Herbert Perey was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D)

Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 29-AS-20221025102303

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: 03/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/24/2023 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a)(1) (a) (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit plan how you will ensure residents receive timely medical care. Submit to CCL by 03/27/2023.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not comply with the section cited above as staff did not obtain timely medical attention for R1 when R1 was discovered with multiple bruises and unable to walk on their own, and was later diagnosed with a fractured left femur, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 6

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
10/25/2022 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20221025102303

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: 5	DATE:	03/23/2023
		UNANNOUNCED	TIME BEGAN:	06:19 PM
MET WITH:	Herbert Perey		TIME COMPLETED:	08:20 PM

ALLEGATION(S):

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9

Resident #1 (R1) sustained pressure injury while in care.

INVESTIGATION FINDINGS:

1
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3
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5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Angel Ascecncio conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA Ascencio met with Administrator Herbert Perey and explained the reason for the visit.

On 10/25/2022, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that Resident #1 (R1) sustained a pressure injury while at the facility.

On 10/26/2022, between 1:52pm and 3:35pm, Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced initial complaint visit. LPA Lopez initially met with facility staff who contacted Administrator Herbert Perey and advised him of the visit. The Administrator arrived shortly after the visit began. The LPA conducted an entrance interview explaining the reason for the visit. Beginning at 1:58pm, the LPA conducted a physical plant tour with staff and reviewed facility records. Copies of pertinent records were obtained.
Continued on LIC 9099 - C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 29-AS-20221025102303

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: 03/23/2023

NARRATIVE

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The LPA determined further investigation was needed and informed the Administrator that the Community Care Licensing Division (CCLD) Investigations Branch (IB) Investigator Douglas Real was assigned to complete the investigation.

A review of R1’s hospital medical records, revealed R1 was admitted to St. John’s Regional Medical Center on 10/23/2022 due to left hip pain. R1 was found to have a left femur neck fracture along with a urinary tract infection and dysphagia (trouble swallowing). R1 was noted as having numerous other health conditions including a history of atrial fibrillation, dementia, Parkinson’s disease, hypertension, and hyperlipidemia and R1’s health was declining. R1’s resident representative decided to transition R1 to hospice for comfort care and R1 passed away in the hospital on 11/02/2022. No abuse or neglect concerns were noted in the medical records. There was no information in the medical records that indicated R1 had a pressure injury. The hospital records noted R1’s skin was warm and dry, no ulcerations.

Interviews conducted during the complaint investigation did not indicate R1 suffered from any pressure injuries. Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to support the allegation. Therefore, the allegation “Resident sustained pressure injury while in care” is deemed Unsubstantiated at this time.

Exit interview conducted, copy of this report issued.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 6