A Peace of Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 10:49 AM. LPA met with facility staff who contacted the facility Administrator Herbert Perey. The Co-Administrator Mischelle Perey arrived to the facility at approximately 11:10 AM. LPA and Co-Administrator were later joined by Administrator. Entrance interview was conducted and the reason for the visit was explained. Beginning at approximately 10:50 AM the LPA, along with the facility staff and later the Administrator and Co-Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: COMMON AREAS: This includes the living room, hallway, and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contained a television, adequate seating, and locked storage for resident medication and files. Additionally, the living room was observed to contain all required postings, the facility telephone, emergency flashlights, and a complete first aid kit. The hallway was observed to be clean and free from any obstructions. The hallway contained closets that contained storage for linens and care supplies. Additionally, the hallway contained a locked laundry room which contained the facility’s washer and dryer in addition to laundry chemicals and care supplies. The dining area was observed to be equipped with adequate seating for resident use and contained an appropriately screened fireplace. Continued on LIC 809C. COMMON AREAS CONT.: LPA observed the dining area and hallway to contain wall mounted fire extinguishers that were fully charged and last serviced on 05/14/2024 which was more than 12 months from the inspection date. LPA informed the Co-Administrator who purchased new fire extinguishers during the visit and installed them at the facility. The facility’s fire and carbon monoxide alarms were tested at 12:14 PM and were functional at the time of the visit. All exits in the facility were observed to contain functioning auditory alarms. KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured under-sink cabinet to contain cleaning chemicals. LPA observed secured drawers to contain knives and other sharp objects. BEDROOMS: There are four (4) bedrooms in the facility; two (2) are dual occupancy resident rooms, two (2) are single occupancy resident rooms. LPA and the Co- Administrator toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. BATHROOMS: There are two (2) bathrooms at the facility. One is designated as a shared/common resident bathroom and one (1) is a private resident bathroom. Both resident bathrooms were observed to be clean and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured to be between 129.3 and 133.3 degrees Fahrenheit, whish is outside of the range required by regulations. LPA informed the Administrator who adjusted the temperature regulator on the water heater and agreed to submit proof of appropriate water temperature to LPA. The private bathroom contained a secured storage which contained grooming supplies. Continued on LIC 809C. GARAGE: The garage was observed to be locked and inaccessible to clients in care. LPA observed the garage to contain an extra refrigerator/freezer, extra care supplies, and sufficient emergency water supplies. LPA observed the garage to contain two (2) makeshift bedrooms which included supports, wooden walls, and a door. LPA interviewed the Co-Administrator about the rooms. The Co-Administrator stated that the rooms were installed in June of 2025 and facility staff were utilizing the rooms. The Co-Administrator confirmed that they did not obtain building permits for the two (2) rooms, did not inform Community Care Licensing Division (CCLD) of the construction, and did not obtain a fire inspection for the rooms. LPA informed the Administrator and Co-Administrator that the constructed rooms are a violation of the facility’s fire clearance which is a zero-tolerance violation and an immediate civil penalty of $500 is being assessed on today’s date (12/18/2025). LPA informed the Administrator and Co-Administrator that failure to remove the structures could result in the assessment of additional civil penalties. OUTDOOR SPACE: The facility has one (1) emergency exit gate located on the side of the facility; LPA observed clear passageways for emergency exit use. The facility had adequate shaded seating outdoors for resident use. LPA observed cameras throughout the outdoors of the facility. RECORD REVIEW: Record review began at 12:19 PM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Five (5) staff files were reviewed. All staff files contained all required documentation and trainings. Four (4) resident files were reviewed. All resident files contained the required documentation. MEDICATION REVIEW: Medication review began at 01:14 PM. Medications for two (2) of four (4) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. Continued on LIC 809C. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last logged emergency disaster drill was conducted on 12/01/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator. INTERVIEWS: LPA interviewed two (2) residents. The residents interviewed stated that staff treat them well and are attentive to their needs. The residents interviewed had no concerns with the facility. LPA interviewed two (2) staff members. The staff members interviewed were knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and current liability insurance. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited and civil penalty assessed. (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 18, 2025

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Staff neglect resulted in resident sustaining a wound requiring hospitalization

Licensing Program Analyst (LPA), Esther Cortez, conducted a subsequent complaint visit to deliver findings for the above allegation. At 12:25 p.m. the LPA met with staff and explained the reason for the visit. At approximately 1:00 p.m., Co-administrator Michelle Perey arrived and was explained the reason for the visit. On 09/23/2024, the Department received a complaint regarding an allegation of Neglect/Lack of Care and Supervision. Staff neglect resulted in Resident 1 (R1) sustaining a wound requiring hospitalization. On 09/25/2024, beginning at 10:45 a.m., LPA Cortez conducted a physical plant tour with the administrator and then began reviewing facility records. Copies of pertinent records were obtained. On 11/22/2024, starting at 12:22 p.m., LPA Cortez conducted four (4) resident and three (3) staff interviews. Medical and Home Health records were requested and reviewed. Report will continue on LIC9099-C, 2nd page. Substantiated On the allegation " Staff neglect resulted in resident sustaining a wound requiring hospitalization"; it is the concern of the Reporting Party (RP) that on 09/18/24, Resident 1 (R1) was admitted to St. John’s Regional Medical Center, with a gluteal abscess that was so deep, muscle and fat was able to be seen. RP believes R1 was neglected by facility staff due to their condition and R1 was possibly “never turned” by staff. To investigate the allegation the LPA conducted a file review and interviews. According to medical and home health records reviewed, R1 was initially admitted to Camarillo Health Care Center (CHCC) on 07/21/2024 for “encounter for surgical aftercare following surgery on the genitourinary system”. On 08/19/2024, R1 was discharged and admitted to the A Peace of Home facility. The discharge paperwork from CHCC did not indicate a pressure injury. However, home health records reviewed indicated that on 08/22/2024, R1’s Patient Information Report notated R1 had a left foot unstageable pressure ulcer and a coccyx stage 3 pressure ulcer: measurements at 6.65 CM X 6.5 CM and that all wounds were acquired prior to board and care transfer. Facility staff able to assist with providing wound care 1 time a week or as needed, with home health twice weekly for a total of 3 times a week. On 08/26/2024, a home health nurse cleansed sacral wound with normal saline and there were no signs or symptoms of infection. New wound orders called in for left heel wound. On 08/29/2024, R1 received wound care, pressure relieving measures with skin management for prevention of skin breakdown, no new skin concerns noted at visit. Diet was noted as a concern for board and care as it was reported R1 eats 15% of total daily solids. R1 and care staff were instructed on the importance of appropriate measures to prevent skin injury/breakdown including routine inspection of skin, turning schedule/offloading, keeping skin clean and dry especially over bony prominences, encourage adequate nutrition and hydration and leave blisters intact. On 09/01/2024, a home health nurse noted that R1 was diagnosed with UTI on Friday August 30th, 2024, R1 did not fully engage in conversation due to increased tiredness, and heart rate range between 110 to 113 throughout visit. Nursing interventions were listed as the following: R1 and caregivers educated on repositioning every 2 hours to help heal pressure injuries and prevent further skin breakdown, educated on increasing protein intake as tolerated if not contraindicated to help with the healing process, and educated on signs and symptoms of infection. On 09/04/2024, a case conference note indicated bedbound, wound care, pressure ulcers, cervical spine issues, recently diagnosed with UTI, on antibiotic as skilled reason for home health services, and that R1 is being seen by mobile wound specialist, waiting to have pet scan and recently had MRI. On 09/05/2024, a home health nurse noted that they called the office of Dr. West and gave report that R1 had not been eating or drinking well for 4 days and a feeding tube was being requested. Report will continue on LIC9099-C, 3rd page. Additionally, on 09/06/2025, a home health nurse noted that they were informed by R1’s case manager that R1 was admitted to St. Johns Regional on 09/04/2024 with Dx sepsis, UTI, an abscess, and R1 was on O2. On 09/08/2024, it was noted that R1 was scheduled for drainage procedure later in the day. On 09/13/2024, it was noted R1 was now at USC-Keck Hospital and home health nurse spoke with R1’s nurse at USC. On 09/19/2024, it was noted that R1 was transferred back to St. Johns Regional on 09/18/2024 as R1 was more stable. On 09/25/2024, it was noted a home health nurse spoke with R1’s case manager at St. John’s Regional and it was stated R1 needed a higher level of care as they still had a wound vac in place and wound was not looking good, and it was recommended for R1 to go to SNF instead of Board and care. The Administrator stated that R1 had what appeared to be an "unstageable pressure ulcer” upon admission and that when they did the pre-assessment at CHCC, R1 refused to be seen and went based on photos that were shown to him and the information that was provided. The Administrator revealed that the nurse involved with R1’s care at CHCC let him know he had a diabetic ulcer on their heel, as well as an excoriation on their sacrum, coccyx region, and based on the information that was shared they agreed R1 would be a good fit for the facility. However, upon admission, R1’s wounds were more severe and not as described. The Administrator notified R1’s POA that R1’s wounds were more severe than they thought, they were more of a pressure ulcer and R1 needed a higher level of care, however R1 refused to go the hospital and wanted the home care aspect and nursing visits as opposed to hospitalization. The Administrator further revealed that during R1’s stay at the facility after home health diagnosed the wound as a pressure ulcer, they emphasized to R1’s POA that the facility might not be the appropriate place for R1, and they needed to get treatment at a wound center or the hospital, it did need the clinician care, higher frequency care as it was a pressure injury and the POA eventually was able to convinced R1 to go to the hospital. Staff interviews revealed that staff did not get wound treatment training by a home health nurse. Staff either received training on basic treatment to care for R1’s wound by the Administrator or did not get any training on how to treat the wound, even though R1’s dressing would get changed either by the nurse or sometimes by the staff. Staff further revealed that they would reposition R1 every 2 to 3 hours. Based on record review and interviews conducted, there is sufficient evidence to support the allegation occurred. The Administrator admitted and retained R1 with a prohibitive health condition (who needed a higher level of care) in direct violation of regulations. Report will continue on LIC9099-C, 4th page. R1 had a rapid progression of a pre-existing Stage 3 pressure ulcer to a severe gluteal abscess and sepsis within 2 weeks. Despite HH visits and staff claiming repositioning R1 every 2 hours, R1’s condition deteriorated rapidly between 08/19/2024 and 09/04/2024. A UTI was diagnosed on 08/30/2024, which, coupled with the existing pressure ulcer, required a higher level of care. Additionally, the care staff should not be changing R1’s dressings as they are not skilled professionals. Furthermore, file review did not provide information or documentation to support which caregivers were provided with training on R1’s wound care. Therefore, the allegation “Staff neglect resulted in resident sustaining a wound requiring hospitalization” is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). An immediate $500 civil penalty was issued today. Administrator Michelle Perey was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Exit interview conducted, copy of this report issued.the state’s words, verbatim · CDSS document, Oct 31, 2025 · control 29-AS-20240923160550

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Nov 3, 2025

87615(a)(1) Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained... (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as R1 had a left foot unstageable pressure ulcer and a coccyx stage 3 pressure ulcer and R1 was not admitted to hospice care at that time, which posed an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Oct 31, 2025

Plan of correction: The Administrator agreed to submit a corrective action plan outlining specific steps to ensure future compliance with all admission, retention, care, assessment and relocation regulations.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(d) · Plan of correction due date: Nov 3, 2025

The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. This requirement is not met as evidenced by: Based on interviews and records review the licensee did not comply with the section cited above as the Administrator did not demonstrarte sufficient knowledge, and qualifications as an Administrator, admitting & retaining R1 with a prohitivive health condition which poses an immideatethe state’s words, verbatim · CDSS document, Oct 31, 2025

Plan of correction: Licensee agreed to review reg cited and submit a statement of understanding, along with a written plan on how they will ensure future compliance then send to LPA via email by COB 11/03/2025. health, safety or personal rights risk to persons in care.

Type of visit: Required - 1 Year

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. 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.the state’s words, verbatim · CDSS document, Dec 17, 2024

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: 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

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 (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) (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.the state’s words, verbatim · CDSS document, Jul 29, 2024 · control 29-AS-20230605162215

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual continuation visit. LPA met with Administrator Herbert Perey and explained the reason for the visit. The LPA completed record review and medication review. STAFF RECORDS: LPA reviewed staff records for two staff. Training was complete. All staff have CPR/First Aid certifications. All staff scheduled to work at the facility are fingerprint cleared and associated to the facility. RESIDENT RECORDS and MEDICATION: LPA reviewed two residents' records. Resident files included pre-admission appraisals, needs and services plans, physician's reports, and admission agreements. Medications appear to be given as prescribed based on review of medications and the centrally stored medication and destruction records. EMERGENCY DISASTER PLAN: The emergency disaster plan was complete. The facility conducts disaster drills quarterly on each shift. LPA interviewed two staff; there were no concerns. LPA attempted to interview two residents. One resident was unable to answer questions due to their condition and one resident was sleeping. No deficiencies observed during today's visit. Exit interview conducted. Report emailed to Administrator.the state’s words, verbatim · CDSS document, Jan 10, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 8:17 a.m. LPA met with Administrators Mischelle Perey and Herbert Perey and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher appeared fully charged and was last inspected on 4/24/2023. KITCHEN: LPA observed knives are stored in a locked drawer and chemicals are stored in a locked cabinet under the sink. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of perishable and non-perishable food and emergency water. Hot water temperature measured 119.8*F. BEDROOMS: The LPA observed two double-occupancy bedrooms and two single-occupancy bedrooms which were clean and furnished appropriately. RESTROOMS: The two restrooms were clean and sanitary and in operating condition. COMMON SPACES: At the time of the visit, the living room and dining room furniture was observed to be in good condition. The LPA observed the required postings throughout the facility. The backyard patio is equipped with furniture for residents' use. The garage and laundry room were locked. There is additional food stored in the refrigerator in the garage along with refrigerated medication. Medication is also stored in a locked cabinet in the living room. INFECTION CONTROL: The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility has appropriate plans in place in the event of clients and/or staff showing symptoms of COVID or testing positive for COVID. LPA will return at a later date to continue this annual inspection. No deficiencies observed during today's visit. Exit interview conducted. Report emailed to Administrator.the state’s words, verbatim · CDSS document, Dec 8, 2023