567609929-7-30-2024-29-AS-DPEA-D7PTWB-20240731150516

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609929
Report Date: 07/29/2024
Date Signed: 07/30/2024 08:24:32 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
06/05/2023 and conducted by Evaluator Teresa Camara

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20230605162215

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: 4	DATE:	07/29/2024
		UNANNOUNCED	TIME BEGAN:	03:32 PM
MET WITH:	Herbert Perey		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Staff is overmedicating resident
Staff is not providing appropriate incontinence care
Staff is not allowing resident to have privacy on the phone
Resident is not receiving proper nutrition which is causing weight loss
Resident has developed wounds for which they are not receiving medical care
Facility does not offer activities or exercise to residents
Staff pressure resident to go on hospice

INVESTIGATION FINDINGS:

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LIcensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit regarding the above noted allegations. LPA met with administrator Herbert Perey and explained the reason for the visit.

On 6/13/2023, LPA conducted a facility tour, interviewed witnesses, residents, and staff; and obtained records. During LPA's visit on 7/29/2024, LPA conducted interviews with staff.

Based on interviews with staff and review of records, resident 1 (R1) had no medication that would have made them overly sedated. All medications were given as prescribed and R1 readily took the medication. Therefore, the allegation staff overmedicated R1 is deemed Unsubstantiated at this time.

(continued on LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

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-20230605162215

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: A PEACE OF HOME	FACILITY NUMBER: 567609929
	VISIT DATE: 07/29/2024

NARRATIVE

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(continued from LIC9099)

Based on interviews with staff and witnesses, R1 was provided incontinence care as needed during the day and at night R1 wore a PureWick external catheter. LPA observed R1 on 6/13/2023, R1 was resting comfortably in bed. There were no foul odors in the room. LPA also observed a clean PureWick external catheter machine at the foot of the bed which was used at night. Therefore, the allegation staff was not providing appropriate incontinence care is deemed Unsubstantiated at this time.

Based on interviews with witnesses and staff, R1 took phone calls on the facility cordless phone. Staff would take the phone to R1 in their room. R1 would decide whether to use the speaker phone feature or hold the phone to their ear. R1's roommate stated they would leave R1 in the room alone while R1 was on the phone. Therefore, the allegation staff did not allow for privacy on the phone is deemed Unsubstantiated at this time.

Based on interviews with witnesses and staff, when R1 first moved into the facility R1 would eat meals inconsistently. Staff tried giving R1 their favorite foods and supplements such as protein drinks. During the end, R1 completely lost their appetite and after two days of missing meals R1 was sent to the hospital. Therefore, the allegation resident was not receiving proper nutrition is deemed Unsubstantiated at this time.

Based on interviews with witnesses and staff, R1 needed to see a podiatrist for issues on R1's feet. R1's POA wanted to make the arrangements for transporation themselves. The administrator offered to make transportation arrangements but the POA refused. R1 did not have any wounds but did have some trouble with their nails/toes. Eventually, R1 was taken to the hospital by ambulance. Therefore, this allegation is deemed Unsubstantiated at this time.

Based on interviews with witnesses, residents, and staff, the facility offers different activities such as short walks, chair exercises, reading comprehension, and puzzles. Witnesses stated R1 did not have energy to participate in activities. R1 did have frequent visitors for personal interaction. Therefore, this allegation is deemed Unsubstantiated at this time.

(continued on page 3; LIC9099C)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20230605162215

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: A PEACE OF HOME	FACILITY NUMBER: 567609929
	VISIT DATE: 07/29/2024

NARRATIVE

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(continued from page 2; LIC9099C)

Based on interviews with witnesses and staff, the administrator contacted R1's medical Power of Attorney (POA) as R1 had not eaten in two days. The administrator asked the POA to decide whether they wanted R1 taken to the hospital or placed on hospice as the administrator was aware hospice had been part of the converstaion the POA was having with other family members. The administrator only wanted some sort of care for R1; either medical intervention or comfort care measures from hospice. The administrator did not pressure the family to place R1 on hospice. Therefore, the allegation staff pressured resident to go on hospice is deemed Unsubstantiated at this time.

No deficiencies observed. Exit interview conducted and report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC9099 (FAS) - (06/04)

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