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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609929
Report Date: 03/23/2023
Date Signed: 03/27/2023 08:59:06 AM


Document Has Been Signed on 03/27/2023 08:59 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/27/2023 08:45 AM

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

NARRATIVE
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This report was amended on 03/27/2023 due to additional information obtained.

During the complaint investigation of complaint #29-AS-20221025102303, the following deficiencies were observed:

On 05/17/2022, Resident #1 (R1) was diagnosed with an acute urinary tract infection (UTI). On 10/23/2022, R1 sustained an unwitnessed fall resulting in bruises and left femur fracture. Family Representative stated they were not notified of the incident. Administrator and staff stated they did notify family the day of R1's incident. There was a Special Incident Reports (SIRs) submitted to Community Care Licensing (CCL) that was misfiled.

On 10/23/2022, at 8:00am, staff discovered R1 had multiple bruises, was unable to get out bed and walk. At 1:00 p.m., R1’s representative observed that R1 was in pain and took R1 to the hospital where R1 was diagnosed with a left femur fracture.

Citations issued, exit interview, appeal rights given.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 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.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/27/2023 09:01 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/27/2023 08:50 AM

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: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2023
Section Cited

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87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided... ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person…
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Licensee will submit a plan on how you will ensure residents' representatives/physicials will be notificed of change in condition. Submit plan to CCL by 03/31/202
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This requirement is not met as evidenced by:

Based on interviews, R1’s resident representative/physician was not notified when R1 had a change of condition, which posed a potential health and safety risk to residents 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: Angel AscencioTELEPHONE: 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
LIC809 (FAS) - (06/04)
Page: 2 of 2