A Peaceful Haven Residential Community

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gary Tan, met with staff Teresa Giron for a One (1) Year Required visit for this facility. Ms. Giron called the Administrator Claudia Gutierrez and explained the reason for the visit. Administrator designated Ms. Giron to sign the report. A tour of the physical plant was conducted with the administrator at 12:19 PM. The facility is a single storey house with a total of three (3) bedrooms and three (3) bathrooms currently occupying four (4) residents. The facility is fire cleared for six (6) non-ambulatory residents, one (1) of which may be bedridden in Room #1. Hospice waiver for six (6) residents. Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted: KITCHEN: The facility has a Kitchen that is equipped with a refrigerator, microwave, stove, dishwasher and sink. There was an adequate supply of emergency food. Knives were kept locked in a kitchen drawer. Cleaning supplies and other toxins are stored in the garage which was locked during visit. BEDROOMS are adequately furnished with appropriate furniture and lighting system. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. BATHROOMS were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at a range of 110.1°F to 117.2°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the linen cabinet. (continued on LIC 809-C) (continued from LIC 809) LAUNDRY ROOM: The laundry room is located in the garage. Laundry detergents and other cleaning agents were locked in a cabinet in the garage. The cleaning supply cabinet was observed to be locked during visit. COMMON AREAS: Living and dining room furniture were also checked. The living room is neat and clean along with dining The facility maintains a comfortable temperature at 74°F. Dual smoke/carbon monoxide detectors are hardwired and inter connected and observed to be operational. The fire extinguisher is located in the kitchen was observed filled and last bought on 12/07/25. MEDICATIONS: The medication cabinet is located in the bedroom hallway and was observed to locked and inaccessible during visit. A complete first aid kit is located in the kitchen. Staff/Resident Records: Resident records were reviewed and observed to be complete and updated at this time. Staff records were also reviewed and observed to be complete and updated at this time. SURROUNDING GROUNDS: The backyard of the facility has a covered patio and backyard furniture to accommodate the residents. The Garage is converted into an office/staff break room/laundry area. There is a tool shed on the backyard separated by a 3' gate and inaccessible to residents. There is a drive way at the back of the facility which could park three (3) cars at a time. Disaster drill was last conducted on 10/28/25. Required posting are observed to be complete and current and displayed properly at the facility. Exit interview conducted. Copy of this report.the state’s words, verbatim · CDSS document, Dec 7, 2025

Allegation investigated: Staff are not meeting residents nutritional needs Staff are not mitigating the spread of infectious outbreaks in the facility Staff are mismanaging residents medications Staff did not seek timely medical attention for resident in care

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegations. LPA met with Administrator Claudia Gutierrez and explained the reason for the visit. LPA conducted a physical plant tour at 9:10 AM, requested copies of facility documents relevant to the investigation at 9:30 AM, reviewed records between 9:30 AM to 10:30 AM and interviewed staff and residents between 10:30 AM to 1:00 PM. Regarding the allegation that Staff are not meeting residents’ nutritional needs, it was alleged that the food quality and quantity has suffered at the facility. LPA's observation during today's visit revealed that today's menu consists of sauteed marinated chicken, rice, beans and salad with freshly prepared strawberry lemonade with honey fruit shake. LPA's interview with five (5) residents today between 10:30 AM to 1:00 PM revealed that all five (5) residents stated that they like the food here which is nutritious and delicious and the quality is very good and the quantity is sufficient. (continued on LIC 9099--C) Unsubstantiated (continued from LIC 9099-C) Regarding the allegation that Staff are not mitigating the spread of infectious outbreaks in the facility, it was alleged that there have been severe illnesses that resulted in hospitalization. LPA's record review today at 9:30 AM revealed that there was no record of any current or past client that has an infectious disease at the facility. LPA's interview with the staff revealed that there was no time that there was any resident admitted at the facility nor acquired any infectious disease while living at the facility. Regarding the allegation that Staff are mismanaging residents’ medications, it was alleged that staff often missed Resident1 #1 (R1)'s medications. LPA's record review revealed that R1 was given all of R1's prescribed medication but it was R1 who refused some of R1's medication as noted in R1's Medication Administration Record (MAR). LPA's interview with staff today at 12:04 PM revealed that it was R1 who picked and chose medication to take at any given time so the staff noted in on R1's MAR. Regarding the allegation that Staff did not seek timely medical attention for resident in care, it was alleged that R1 was discouraged from calling 911 at a time when R1 needed care. LPA's interview with the Administrator and staff between 10:30 AM to 1:00 PM, revealed that R1 had own phone and could have called 911 on R1's own and was not discouraged nor anyone at the facility to call 911. LPA's interview with five (5) residents during today's visit revealed that all five (5) of them stated that no one told or discouraged them from calling 911 when they needed to. Based on the information gathered during this and prior visit, these allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Dec 2, 2025 · control 31-AS-20250819145821

Allegation investigated: Staff do not treat client with dignity and respect Staff are not safeguarding clients personal belongings

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegations. LPA met with staff Teresa Giron who called the Administrator Claudia Gutierrez and explained the reason for the visit. Ms. Gutierrez designated Ms. Giron to sign the report. LPA conducted a physical plant tour at 9:12 AM, requested copies of facility documents relevant to the investigation at 9:27 AM and interviewed residents and staff between 9:30 AM to 12:00 PM. Regarding the allegation that Staff do not treat client with dignity and respect, it was alleged that Resident #1 (R1) verbalized psychological abuse by the staff. LPA's interview with R1's roommate or Resident #2 (R2) on 08/19/25 and today at 11:23 AM revealed that it was R1 who was abusive to R2 and other residents, R1 watched TV so loud that R2 could not sleep especially during 1:00 AM to 5:00 AM. LPA's interview with two (2) other aware residents confirmed that R1 was mean to them and always yell and rude to them. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) LPA's interview with staff on 08/19/25 and today at 10:23 AM, revealed that there only once incident that someone yelled at R1, it was R2, in their room because R2 could not sleep as R1 was watching and the TV was loud, further interview with staff also revealed that no staff yelled at R1 and it was R1 who was rude to everyone at the facility and gets angry when things did not go on R1's way. LPA's interview with three (3) aware residents also revealed that three (3) out of three (3) residents stated that the staff are respectful and provide all the care they need. Regarding the allegation that Staff are not safeguarding client’s personal belongings, it was alleged that R1 experienced theft at the facility. LPA's observation on 08/19/25 visit at around 10:00 AM revealed that all the belongings of R1 were still at the facility and carefully packed and being itemized by the administrator to be brought to the new facility where R1 was transferred. LPA's interview with the Administrator today revealed that when R1's belongings were brought to the new facility and the inventory list was presented to R1, R1 signed the list and did not express if anything was missing. Based on the information gathered during this and prior visit, these allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Oct 9, 2025 · control 31-AS-20250814152448

Allegation investigated: Staff do not ensure resident restrooms are clean and orderly Staff are not properly cleaning dishes used for residents Staff do not ensure all persons engaged in food preparation are practicing proper hygiene to prevent contamination.

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPA met with co Administrator Lucy Guttierez and explained the reason for the visit. LPA conducted a physical plant tour at 9:38 AM, requested copies of facility documents relevant to the investigation at 10:00 AM, reviewed records between 10:00 AM to 11:00 AM and interviewed staff and residents between 11:00 AM to 1:30 PM. Regarding the allegation that Staff do not ensure resident restrooms are clean and orderly, it was alleged that there have been continuous issues with unsanitary conditions in the restroom. LPA's observation during this visit and prior visit on 08/19/25 while investigating complaint control no.: 31-AS-20250814152448, revealed that the residents' bathrooms are clean and in proper order. LPA's interview with three (3) residents present during this visit revealed that three (3) out of three (3) residents stated that the bathrooms are always clean and in proper order and they never had any issue with the bathroom. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) Regarding the allegation that Staff are not properly cleaning dishes used for residents, it was alleged that states dishes are not cleaned properly, LPA's observation during this visit and prior visit on 08/19/25 while investigating complaint control no.: 31-AS-20250814152448, revealed that the unused dishes, pots and pans, cups, glasses, plates etc., were all observed to be clean and kept properly in the dish cabinet. LPA's interview with three (3) residents present during this visit revealed that three (3) out of three (3) residents stated that the plates and utensils they use are always clean and the food is good. LPA's interview with the staff during this visit also revealed that the staff always used the dishwashing machine to clean the dishes and utilities. Regarding the allegation that Staff do not ensure all persons engaged in food preparation are practicing proper hygiene to prevent contamination, it was alleged that the staff and have prepared food while sick or coughing and do not use proper equipment to ensure contamination and good hygiene are upheld. LPA's record review today between 10:00 AM to 11:00 AM revealed that the staff had multiple certifications on food handling not only in California but also at Washington State, the staff obtained a food handler permit on 11/08/24 and has a food worker card from Washington state Public Health. LPA's observation today while the staff was preparing food also revealed that the staff was wearing gloves, hair tied neatly and prepared the food in delicate manner. Based on the information gathered during this visit, these allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Aug 26, 2025 · control 31-AS-20250819145821

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Gary Tan conducted a Pre-Licensing Inspection at this facility and met with the applicant representative/Administrator Claudia Gutierrez. The applicant is " A Peaceful Haven Residential Community, Inc.". A fire clearance was approved on 09/11/24 for six (6) non-ambulatory residents, one (1) of which may be bedridden on Room #1. The applicant has an approved hospice waiver for six (6) residents. The facility is a single story house with a total of three (3) bedrooms and three (3) bathrooms. A tour of the physical plant was initiated at approximately 9:55 AM and the following was observed: KITCHEN: The facility has a Kitchen that is equipped with a refrigerator, microwave, stove, dishwasher and sink. There was an adequate supply of emergency food. Knives will be locked in a kitchen drawer. Cleaning supplies and other toxins are stored in the garage which was locked during visit. BEDROOMS: There are three (3) bedrooms designated for clients' use, all are shared bedrooms. The applicant furnished the residents' bedrooms with beds, night stand, chairs, dressers, bedding and linen. The bedrooms have sufficient lighting and storage. BATHROOMS: The facility has two (2) shared bathrooms for clients' use. One (1) bathroom is designated for staff use. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water temperature was measured at a range of 112.7°F to 115.7°F. LAUNDRY ROOM: The laundry room is located in the garage. Laundry detergents and other cleaning agents were locked in a cabinet in the garage. The cleaning supply cabinet was observed to be locked during visit. (continued on LIC 809-C) (continued from LIC 809) COMMON AREAS: These included the living room and the dining area. Living room was furnished with chairs and side tables. The living room area was furnished with a television, a coffee table and sofas to sit the capacity of the facility. There were no visible immediate hazards. There is a working telephone line and internet access to residents. Dual smoke/carbon monoxide alarms were tested and observed to be operable, they are hardwired and interconnected. Fire extinguisher was last bought on 07/27/24 and located in the kitchen area. MEDICATIONS: The medication cabinet is located in the bedroom hallway and has a locking mechanism. A complete first aid kit is located in the kitchen. Staff/Resident Records: Staff and resident records will be kept in the filing cabinet the staff lounge/office/staff break room. SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The backyard of the facility has a covered patio and backyard furniture to accommodate the residents. The Garage is converted into an office/staff break room/laundry area. There is a tool shed on the backyard separated by a 3' gate and inaccessible to residents. There are drive way in front of the facility which could park three (3) cars at a time. Component III was conducted with the Licensee representatives. This report will be sent to Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when the license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview conducted. Copy of this report.the state’s words, verbatim · CDSS document, Oct 24, 2024

Type of visit: Office

Facility Type: Residential Care Facility for the Elderly Application Type: Initial Capacity: 6 Census (if any clients in care): 0 COMP II Participants: CLAUDIA GUTIERREZ, LUCY GUTIERREZ Interview Method: Telephone interview On September 24, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Sep 24, 2024