079200739-9-4-2024-15-AS-TSGN-D8SUZZ-20240904160222

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200739
Report Date: 09/04/2024
Date Signed: 09/04/2024 04:02:33 PM

Document Has Been Signed on 09/04/2024 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	DESIRED PEACE HOME CARE		FACILITY NUMBER:	079200739
ADMINISTRATOR:	LAM, PAUL, K		FACILITY TYPE:	740
ADDRESS:	2181 WAYNE DR		TELEPHONE:	(510) 759-8889
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	6	CENSUS: 4	DATE:	09/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Irma Martinez, Caregiver		TIME COMPLETED:	04:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/04/2024 at 1:20PM, Licensing Program Analysts (LPAs) T. Syess-Gibson and David Doidge conducted an unannounced 1-Year Required inspection. LPAs met with Caregiver Irma Martinez, spoke with Administrator, Paul Lem via telephone, and explained the purpose of the visit. The Administrator arrived at 2:00PM. LPAs observed via CCL website that Administrator Certificate is currently in pending status. Facility has census of 4. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPAs toured the facility with Caregiver, Irma Martinez including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of seven (7) bedrooms, three (3) bathrooms with One (1) bedroom being occupied by staff .All outdoor and indoor passageways are kept free of obstruction. LPAs did not observe any bodies of water. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 110.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and skid mats. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 08/19/2024. Emergency Disaster Plan was last posted on 08/21/2024. First aid kit was observed to be complete. Fire drill was last conducted on 08/01/2024. Continued LIC809C.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DESIRED PEACE HOME CARE	FACILITY NUMBER: 079200739
	VISIT DATE: 09/04/2024

NARRATIVE

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Continued from LIC809

LPAs reviewed Four (4) staff records and all four (4) resident records, residents records were current and complete. LPAs also reviewed medications

During visit LPAs observed the following deficiencies:

At 1:44PM LPAs observed there wasn't a minimum of 7-day supply of non-perishable and 2-day of perishable food for residents in care
At 2:24PM LPAs observed during record review S2, S3 and S4 were all missing Health Screening documents
At 3:17PM during medication review LPAs observed medication in kitchen refrigerator unlocked.

LPAs requested updated copies of the following documents to be submitted to CCLD by 09/11/2024.

· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan
· Liability Insurance
· Current Administrator’s Certificate (upon arrival)

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/04/2024 04:02 PM - 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DESIRED PEACE HOME CARE	FACILITY NUMBER: 079200739
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having medication in the kitchen refrigerator unlocked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/05/2024
	Plan of Correction
1 2 3 4	Administrator immediately placed medication in locked kitchen cabinet . Deficiency cleared during visit

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 09/04/2024 04:02 PM - 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: DESIRED PEACE HOME CARE	FACILITY NUMBER: 079200739
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(11)

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in not having S2,S3 and S4 health Screening documents in staff's personnel records which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/11/2024
	Plan of Correction
1 2 3 4	Administrator agreed to provide an email to CCLD with Staff's Health Screening by POC date

Type B

Section Cited

CCR

87555(b)(26)

87555 General Food Service Requirements (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in not having food supply of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/06/2024
	Plan of Correction
1 2 3 4	Administrator agreed to provide an email with photos of food to CCLD by POC date

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC809 (FAS) - (06/04)

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