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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609929
Report Date: 12/17/2024
Date Signed: 12/19/2024 10:53:35 AM

Document Has Been Signed on 12/19/2024 10:53 AM - It Cannot Be Edited

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 HOMEFACILITY NUMBER:
567609929
ADMINISTRATOR/
DIRECTOR:
PEREY, HERBERT M.FACILITY TYPE:
740
ADDRESS:1227 MIKA WAYTELEPHONE:
(805) 278-9620
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Herbert Perey, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. Upon arrival, LPA met with staff and explained the purpose of the visit. At the time of arrival, there were three (3) staff on duty and six (6) residents in care. Administrator Herbert Perey arrived at approximately 12:50 pm. Co-Administrator Mischelle Perey arrived at approximately 2:03 pm.
Entrance interview conducted.
The facility is a one-story Residential Care Facility for the Elderly (RCFE). Currently, there are two (2) residents on hospice and three (3) residents are bedridden.
A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service.
The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside. There are three (3) fire extinguishers, inspection was current as of 5/14/2024. There are approximately seven (7) dual carbon monoxide alarm/smoke alarms detectors are hard wired and in good working order.
The kitchen area was sufficiently stocked with seven days of non-perishables. LPA observed a minimal amount of fresh vegetables and fresh fruits. Administrator Perey stated the facility recently had a holiday party with approximately 30-35 attendees. Meals served were catered and home-made ethnic dishes. LPA recommended additional fruits and vegetables be on hand, especially after a special event when food has been served. Upon Co-Administrator's arrival at 2:03 pm, Co-Administrator had purchased several fresh vegetables and fresh fruits. Snacks and beverages are readily available for Residents. Frozen foods are properly wrapped and stored appropriately. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean.

Please continue to 809-C, Pg 2.
Kelly BurleyTELEPHONE: (805) 562-0413
Kristin KontilisTELEPHONE: (805) 689-2787
DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: 12/17/2024
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Medications, First Aid kit, and additional first aid supplies are kept in a locked centrally stored cabinet. First aid kit was observed to be complete.
Residents participate independently in outside activities such as corn hole, beach ball toss, music, special occasion celebrations, walks in the yard; indoor activities such as reading activities, television watching, Bingo, chess, painting, coloring, and singing. Families visit and take residents out on excursions such as golfing, shopping, and walks in parks.
The front yard consists of walkway and well-maintained landscaping. The backyard has walkways, garden sitting areas, and is well-maintained for activities and visits. There are no bodies of water. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. A locked garage is located at the front of the home used for storing supplies.
The kitchen, living room, and dining area are neat and clean. The facility maintains a comfortable temperature.
There are two private bedrooms and two shared bedrooms. Bedroom #4 is a shared bedroom with a private bath. Each bedroom has a bed, nightstands, and lights and nightstand lamps to provide sufficient lighting. Bathroom #1 is off the hallway near Bedrooms 1, 2, and 3. All residents have access to Bathroom #1. The bathrooms have secure grab bars and no skid flooring.
Medication inventory revealed an unexplainable under count of one (1) medication for Resident 1 (R1) and an over count of four (4) medications for R1.
Residents’ files were reviewed. LPA noted that on file for each resident was the following: Physician’s Reports, Admission Agreements, Medical Assessments, Identification and Emergency information, Appraisals/Needs Service Plan, and Medication Administration Records (MARs).
All persons associated with the facility have criminal record clearance. Administrator certificate is valid.

Due to time restraints, the annual inspection will be completed at a later date.



The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. Report and Appeal Rights issued at the time of the visit.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/19/2024 10:53 AM - It Cannot Be Edited

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: 12/17/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87465(c)(2) Incidental and Medical Care: ....Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above when there was an unexplainable overcount of four (4) of R1’s prescribed medications and an undercount of one (1) of R1’s medications which poses an immediate health and safety risk to residents in care.
POC Due Date: 12/19/2024
Plan of Correction
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Licensee agrees to provide written statement of Plan in Place to ensure medications are administered as prescribed including but not limited to accurately recording start date, medication count, and timely noting date/time medications are administered. Written statement will be provided to LPA via email no later than POC due date 12/19/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Kelly BurleyTELEPHONE: (805) 562-0413
Kristin KontilisTELEPHONE: (805) 689-2787

DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024

LIC809 (FAS) - (06/04)
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