Our Lady of Peace Home Care

Type of visit: Required - 1 Year

On 12/01/2025 at approximately 1PM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct 1-Year Required visit of this licensed Residential Care Facility for The Elderly (RCFE). LPA was greeted by Staff Member, Esperenzo Konakawa. Administrator, Romeo Cabe arrived shortly after. Facility has an approved fire clearance and capacity for 6 non-ambulatory residents. Facility has an approved hospice waiver for 5 individuals. Upon arrival, LPA was informed that there were 6 residents in care and 2 staff members on-site. Facility is a 1 story building with 6 Resident bedrooms, 2 bathrooms, and common spaces. At approximately 1:30PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 02PM, LPA and Administrator toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility does the grocery shopping once a week. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Staff were in the process of putting up Christmas decoration at the time of this inspection. Toxins are stored in a locked housekeeping closet in the laundry room and under the kitchen sink. Water temperature measured 110.6 degrees F and 112.4 degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire Extinguishers found to be last charged on 26/08/2025 at the time of visit. Carbon Monoxide and smoke detectors were present and in order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in a closet next to the living room. Continued on LIC809-C... Continued from LIC809... LPA reviewed 3 resident records and found all residents have current care plans, signed admission agreements, and physician's report on file. 3 out of 3 residents did not have documentation of signed personal rights: Form LIC613 and Emergency information: Form LIC601 (Technical advice given). Medication records are thorough and contained physician's orders for each resident. LPA reviewed 3 staff records. 3 of 3 records did contain documentation of completed training records as required. Evidence of current first aid and CPR training were current. LPA was presented with proof of current CPR & 1st Aid certification. Administrator Certificate is for Romeo Cabe #7008153740 expires 06/04/2027. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 12/31/2024 (Technical Violation Given). Administrator agrees to conduct disaster drill quarterly and will submit the proof of documentation to CCL by 12/15/2025 Updated copies of the following documents were requested for facility file and are to be submitted to CCL by due date of 12/15/2025: LIC 308 Designation Facility Responsibilities LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan (If Changed) LIC 9020 Register of Facility Client’s/Resident’s Copy/Proof of Updated Certificate of Liability Insurance No deficiencies were observed in the areas inspected, No citations were issued during today’s visit. Exit interview conducted. Copy of report provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Dec 1, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

01/28/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 6 residents in care. There are currently 3 residents on hospice. Facility approved/cleared for 6 non-ambulatory, and hospice waiver for 5. LPA met with Administrator, Romeo Cabe. LPA and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated. LPA observed board games accessible for residents. Facility has a weekly food menu on display. Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Water temperature in sinks accessible to residents in care were measured at 118.1 degrees F which is within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 08/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Sharps were found to be secured in a locked drawer located in the kitchen. There was a supply of hygiene products and paper products available for residents. Toxins are in a locked cabinet located in the laundry room. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Facility conducts fire and emergency disaster drills monthly with the last one being conducted 12/31/2024. Facility has oxygen signs posted at each door for residents who are using oxygen. Facility has staff quarters and is located in the backyard. LPA conducted a review of 4 resident records. All records had the required documentation. LPA conducted review of 3 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file. No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 02/28/2025: continued on LIC809-C LIC500- Personnel Report LIC308- Designation of Responsibility Liability Insurance Exit interview conducted with Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 28, 2025

Type of visit: Required - 1 Year

On 1/23/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Administrator, Romeo Cabe. The facility currently provides care for 5 residents, 3 of which are receiving hospice services and some of which with a diagnosis of dementia. LPA continued with a tour of the facility with Administrator, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers found throughout the facility to be last charged on 8/29/2023 at the time of visit. Both smoke detectors and carbon monoxide detectors throughout the facility were also tested and found to be functioning. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate labeling. Toxins are stored in a locked cabinet in the facility laundry room, under kitchen sink and garage all of which were secured upon inspection. Sharps and other kitchen supplies that could pose danger if available to residents were found secured in the kitchen drawer. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Water was measured at faucets accessible to residents and measured between 112.8 and 115.7 degrees F which is within regulation. During inspection LPA observed several surveillance cameras located in common areas and hallways, none of which record audio. One camera was observed to be facing a resident bedroom. LPA requested for Administrator to reposition or remove the camera as a potential personal rights risk to resident. Technical Advisory issued. Continued onto LIC809-C Medications located in designated closet located in the hallway were found to be secured. LPA conducted a spot check of medications and found all administering and records to be in order. Resident medications are all delivered directly to the facility from the pharmacy. Residents that were awake during the inspection were observed interacting with staff in the common area, watching television for leisure. The facility also offers regular family visits and gatherings as well as encouraging residents to exercise their mobility. There is one emergency exit located in the backyard which was found to be unobstructed. All auditory alarms leading out of the facility including resident bedroom emergency exits were tested and all found to be in working order. Residents utilizing hospital bed or bed rails were found to have appropriate medical orders on file. In addition, signage for use of oxygen were posted at each door of residents requiring the use. Staff quarters were located in the backyard and have been cleared by the fire department for staff to reside. LPA conducted a sample file review for staff and found all staff to have appropriate annual training and 1st Aid & CPR certification on file. LPA also conducted a file review for all residents. Upon review, LPA found that all resident Needs & Service Plans and Physician's Reports to be current. Administrator, Romeo Cabe's Administrator Certification 6026462740 is valid through 6/14/2025. LPA requested the following documents be sent to CCL by COB 2/6/2024: LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Liability Insurance (may be submitted after 2/6/2024, due to renewal) Control of Property/Rental Agreement No deficiencies cited during today's visit.the state’s words, verbatim · CDSS document, Jan 23, 2024