Hospice of Peace, Inc.
A hospice in Fullerton, California 92831
2461 E Orangethorpe Ave, Ste 209, Fullerton, California 92831. (949) 355-2520.
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The short answer
Record last released by CMS on Oct 23, 2026. We couldn’t read Centers for Medicare & Medicaid Services’ list since Oct 27, 2026: qcor.cms.gov now refuses our reader. This record is as of then.
- 27 deficiencies cited in the last three years
- Not rated family caregiver rating
- 9of 10 CMS’s Hospice Care Index
Each figure’s source sits beside it, in its section below.
What these words mean3
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
- Condition-level deficiency
- For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual.
What did inspectors find?
27 deficiencies cited in the last three years
The middle of the 83 hospices serving ZIP code 92831 had 8.
The last inspection on record was on Jul 24, 2024: a follow-up inspection by The Joint Commission.
3 deficiencies at condition level, the more serious of CMS’s two levels
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
When those deficiencies happened
27 deficiencies in 2 months of the last 36. Last cited Jul 2024. Most serious: Condition-level. The last 3 years, to Oct 27, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Jul 24, 2024: follow-up inspection by The Joint Commission1 deficiency
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Program scope (42 CFR 418.58(a)(1))
“Observed in Document Review. Interview with Leadership and review of the QAPI program/meeting minutes revealed no documented data since fourth quarter of 2023. Leadership shared the QAPI meeting was completed in April for first quarter with all the data and documentation given to the Quality Coordinator and not available to review at the time of this survey. This was reviewed, discussed, and validated with the Director of Patient Care Services.”
Jan 5, 2024: reaccreditation inspection by The Joint Commission26 deficiencies
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Infection control (42 CFR 418.60)
“Observed in Data Session. During the Data session if was noted that the organization had not maintained a written infection control program for the protection of patients, families, visitors, and staff and included surveillance, identification, prevention, control and investigation of infectious and communicable diseases. This was confirmed with the Administrator and DPCS present.”
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Control (42 CFR 418.60(b))
“Observed in Data Session. During the Data session if was noted that the organization did not implement infection prevention and control activities including surveillance, to minimize, reduce, or eliminate the risk of infection. This was confirmed with the Administrator and DPCS present.”
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Services (42 CFR 418.100(c)(1)(v))
The inspectors’ words, 96 words
“Observed in HR File Review. During review of Human Resource files it was noted that the organization did not provide hospice aide services. For example, on the first day of survey during discussion the DPCS and Administrator stated that they did not currently have patients being seen by an aide, but they had in the past and had an aide available if needed. However, on the second day of survey during HR file review the DPCS and HR staff member stated they do not have an aide on staff and no contract with any aide service.”
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Content of comprehensive assessment (42 CFR 418.54(c)(6)(i))
The inspectors’ words, 92 words
“Observed in Patient Home. In 1 of 3 home visits conducted, it was noted that the organization did not assess for potential medication related problems including adverse effects, drug reactions, significant side effects, and significant drug interactions, including ineffective drug therapy, duplicate drug therapy, and noncompliance with drug therapy. For example, during HV#3 the hospice nurse failed to conduct a medication assessment. She asked if there had been any changes to medications and discussed medication for pain that the patient used as needed, but did not complete an assessment of patient’s medications.”
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Content of comprehensive assessment (42 CFR 418.54(c)(7))
“Observed in Record Review. In 1 of 2 patient records reviewed, for bereavement services it was noted an initial bereavement assessment was not completed. For example, in RRBR#1 there was no documentation of an initial bereavement assessment. This was confirmed with the Administrator.
”
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Content of plan of care (42 CFR 418.56(c)(1))
The inspectors’ words, 143 words
“Observed in Record Review. In 2 of 10 patient records reviewed, it was noted that the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. For example, during record review HV#2 it was noted that the fall risk assessment was completed on admission and documented as high risk and the POC did not include related goals and interventions related to the fall risk. This patient record included documentation that the patient fell twice during one month following admission to hospice, was evaluated and there were no changes to the POC to include goals and interventions for falls. For example, during record review HV#3 it was noted that the fall risk assessment completed on admission documented high risk for falls and the POC did not include related goals and intervention for falls.”
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Program scope (42 CFR 418.58(a)(1))
“Observed in Data Session. During the Data session it was noted that the quality assessment and performance improvement program did not demonstrate improvement in the indicators related to improved palliative outcomes and hospice services. This was confirmed with the DPCS and Administrator present.”
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Program data (42 CFR 418.58(b)(1))
“Observed in Data Session. During the Data session it was noted that the hospice did not use quality indicator data, including patient care and other relevant data, in the design of its quality assessment and improvement program. This was confirmed with the DPCS and Administrator present.”
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Program data (42 CFR 418.58(b)(2)(i))
“Observed in Data Session. During the Data session it was noted that the hospice did not use the data collected to monitor the effectiveness and safety of services and the quality of care. This was confirmed with the DPCS and Administrator present.”
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Program data (42 CFR 418.58(b)(2)(ii))
“Observed in Data Session. During the Data session it was noted that the hospice did not use the results of data analysis to identify improvement opportunities. This was confirmed with the DPCS and Administrator present. Observed in Data Session. During the Data session it was noted that the hospice did not analyze and compare internal data over time to identify levels of performance, patterns, trends, and variations. This was confirmed with the DPCS and Administrator present.”
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Program data (42 CFR 418.58(b)(3))
“Observed in Data Session. During the Data session it was noted that the hospice’s governing body did not approve the frequency and detail of the data collection. This was confirmed with the DPCS and Administrator present.”
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Program activities (42 CFR 418.58(c)(1)(ii))
“Observed in Data Session. During the Data session it was noted that the hospice did not select performance improvement activities that affect palliative outcomes, patient safety, and the quality of care and that were based on the prevalence and severity of the problems in it’s high volume, high risk areas. This was confirmed with the DPCS and Administrator present.”
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Program activities (42 CFR 418.58(c)(2))
“Observed in Data Session. During the Data session it was noted that the hospice did not collect data on adverse patient events. This was confirmed with the DPCS and Administrator present.”
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Program activities (42 CFR 418.58(c)(3))
“Observed in Data Session. During the Data session it was noted that the hospice did not act on improvement priorities. This was confirmed with the DPCS and Administrator present.”
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Executive responsibilities (42 CFR 418.58(e)(2))
The inspectors’ words, 139 words
“Observed in Data Session. During the Data session it was noted that performance improvement did not occur organization wide. This was confirmed with the Administrator and DPCS present. Observed in Data Session. During the Data session it was noted that as part of performance improvement, leaders did not delegate the following: - Set priorities for data collection, performance improvement activities, and patient health outcomes - Give priority to high-volume, high-risk, or problem-prone processes for performance improvement activities Note: Examples of areas of risk include blood-borne infections, wound care, undetected urinary tract infections, oxygen-related fires, and patient handoff to or from the home care organization. - Identify the frequency of data collection for performance improvement activities - Reprioritize performance improvement activities in response to changes in the internal or external environment This was confirmed with the Administrator and DPCS present.”
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Prevention (42 CFR 418.60(a))
The inspectors’ words, 253 words
“Observed in Data Session. During the Data session if was noted that the organization’s written infection prevention did not include surveillance, to minimize, reduce or eliminate the risk of infection. This was confirmed with the Administrator and DPCS present. Observed in Patient Home. In 3 of 3 home visits conducted, it was noted that the organization did not implement infection prevention as planned. For example, during HV#1, #2 and #3 the nurses failed to perform hand hygiene consistent with the organization’s Hand Hygiene policy.
During HV#1 and HV#2 the nurse failed to perform hand hygiene after removing gloves greater than 2 times at each visit. During HV#3 the nurse performed hand hygiene at the appropriate times however each opportunity of performing hand hygiene, hand soap and water and sanitizer, was followed by the nurse shaking or waving her hands to completely dry them. Observed in Patient Home. In 2 of 3 home visits conducted, the organization did not implement infection prevention and control activities when performing disinfection of medical supplies. For example, during home visits #1 and #2 the disinfectant manufacturer instructions for use were not followed as evidenced by: the nurse did not follow contact time (wet time) as specified in the Lysol wipe disinfectant manufacturer’s IFUs and packaging. For example, during HV#2 the blood pressure machine fell to the floor. The nurse picked it up placed it on the bed and continued performing vital signs without any cleaning or disinfecting of the machine after it was picked up off the floor. 
”
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Control (42 CFR 418.60(b)(2)(i))
“Observed in Data Session. During the Data session if was noted that the organization had not identified infection risks based on its geographic location, community, and population served; the care, treatment, or services it provides; the analysis of its surveillance activities and other infection control data. This was confirmed with the Administrator and DPCS present.”
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Control (42 CFR 418.60(b)(2)(ii))
The inspectors’ words, 148 words
“Observed in Data Session. During the Data session if was noted that the organization’s written infection prevention did not address its prioritized risks. This was confirmed with the Administrator and DPCS present. Observed in Data Session. During the Data session it was noted that the organization’s written infection prevention did not address improving compliance with hand hygiene guidelines. This was confirmed with the Administrator and DPCS present. Observed in Data Session. During the Data session it was noted that the organization’s written infection prevention did not address limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This was confirmed with the Administrator and DPCS present. Observed in Data Session. During the Data session it was noted that the organization’s written infection prevention did not include limiting the spread of infections associated with procedures. This was confirmed with the Administrator and DPCS present.”
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Recruiting and retaining (42 CFR 418.78(c))
“Observed in Tracer Activities. During discussion with the Volunteer Coordinator it was revealed that the organization did not have any active volunteers following the change of ownership 6 months ago and was unable to provide any documentation prior to the change of ownership. The organization was unable to provide documented efforts to recruit volunteers. This was discussed with the Volunteer Coordinator present.
”
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Cost saving (42 CFR 418.78(d))
“Observed in Tracer Activities. During discussion with the Volunteer Coordinator it was revealed that the organization was not able to provide documented cost savings achieved through the use of volunteers following the change of ownership 6 months ago and was unable to provide any documentation of cost savings prior to the change of ownership. This was discussed with the Volunteer Coordinator present.”
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Level of activity (42 CFR 418.78(e))
“Observed in Tracer Activities. During discussion with the Volunteer Coordinator it was revealed that the organization did not have any active volunteers following the change of ownership 6 months ago and was unable to provide any documentation prior to the change of ownership. The organization was unable to provide documentation of an amount that equals 5% of the total patient care hours of all paid hospice employees and contract staff. This was discussed with the Volunteer Coordinator present.”
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Governing body and administrator (42 CFR 418.100(b))
“Observed in Data Session. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by…condition level findings at 418.60, 418.60(b), 418.78, 418.100, 418.100(c)(1)(v), and 418.58.
”
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Training (42 CFR 418.100(g)(3))
“Observed in HR File Review. In 2 of 7 HR files reviewed, it was noted that staff competence was not initially assessed and documented as part of orientation. For example, in the Volunteer Coordinator file only 1 page of the 3 page competence document was completed with no signatures. For example, in the Medical Director’s file there was no documentation of initial competence. This was discussed with the Office Manager and DPCS present.”
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Content (42 CFR 418.104(a)(7))
“Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the medication list was inaccurate. For example, during HV#3 the LVN assessed the patient’s pain and discussed the patient’s pain with the caregiver. The caregiver reported that the patient used Tylenol as needed for pain and the medication list did not include Tylenol.”
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Written agreement (42 CFR 418.112(c))
“Observed in Tracer Activities. During contract review it was noted that the contract with a wound care company was not valid. The contract had typed names on the signature line and the organization was unable to provide a copy with signatures. This was confirmed with the Office Manager and DPCS present.”
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N/a (42 CFR 418.110(k))
“Observed in Patient Home. In 1 of 3 home visits conducted, it was noted that the nurse did not follow the organization’s bag technique policy. For example, the organization’s policy Bag Technique included that the bag should not be placed on the patient’s floor however during home visit #1 the nurse placed the bag on the kitchen floor while performing medication review. This was discussed with the DPCS.
”
All 3 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Jul 24, 2024 | Follow-up inspection by The Joint Commission | 1 deficiency cited |
| Feb 19, 2024 | Follow-up inspection by The Joint Commission | No deficiencies cited |
| Jan 5, 2024 | Reaccreditation inspection by The Joint Commission | 26 deficiencies cited |
Is it certified?
- Medicare-certified hospice since Feb 16, 2021.
- CMS doesn’t list its type of ownership.
- Cited at For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. in the last three years: it didn’t meet a whole condition of Medicare’s rules.
CMS, Hospice General Information. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Has anything been proven against it?
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- 0 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Who does the caring?
- From Medicare claims (Jan 1, 2023 to Dec 31, 2024): 11.9 nurse care minutes per routine home care day, 11.9% of skilled nursing minutes at weekends and a visit near death for 71.4% of patients who died.
- Where its patients were cared for (Jan 1, 2024 to Dec 31, 2024): 96% at home, 4% in assisted living.
CMS, Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | This provider |
|---|---|
| Nurse care minutes per routine home care day | 11.9 min |
| Skilled nursing minutes at weekends | 11.9% |
| Visits near death | 71.4% of patients who died |
Who owns it?
- 17 owners or officers are people: Chet Khay (owns 5% or more directly, 20%); Chet Khay (corporate officer, 20%); Chet Khay (corporate director, 20%); Chet Khay (managing employee (on the payroll), 20%); Glenn D Dayap (owns 5% or more directly, 20%); Glenn D Dayap (corporate officer, 20%); Glenn D Dayap (corporate director, 20%); Glenn D Dayap (managing employee (on the payroll), 20%); Mario Curti (owns 5% or more directly, 20%); Mario Curti (corporate officer, 20%); Mario Curti (corporate director, 20%); KY Minh Tran (owns 5% or more directly, 20%); KY Minh Tran (corporate officer, 20%); KY Minh Tran (corporate director, 20%); Vu Q Phan (owns 5% or more directly, 20%); Vu Q Phan (corporate officer, 20%); Vu Q Phan (corporate director, 20%).
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospice All Owners and Hospice Enrollments. Released Sep 29, 2026. Updated quarterly.
What do families say?
- CMS gives no family caregiver survey rating: “The number of cases is too small to report Star Ratings.”
- CMS’s Hospice Care Index: 9 of 10 (Jan 1, 2023 to Dec 31, 2024).
- 87.5% of patients were assessed on all seven of CMS’s measures at the start of care (Oct 1, 2024 to Sep 30, 2025).
CMS, CAHPS Hospice Survey and Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Family caregiver survey ratingCMS star rating from its survey of patients’ family caregivers, 1 to 5 | Not rated |
| Hospice Care IndexCMS’s Hospice Care Index, 0 to 10 (higher is better): a point for each of ten measures from Medicare claims on which the hospice meets CMS’s threshold | 9 of 10 |
How does it compare nearby?
- Of the 83 hospices CMS’s data show serving patients in ZIP code 92831, where this hospice’s office is, the middle number of deficiencies cited in the last three years was 8; this one had 27.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
| Place | Deficiencies, 3 years |
|---|---|
| California’s Best Hospice Services, Inc. | 7 |
| Hospice of Peace, Inc. This hospice | 27 |
| Life Touch Care | 34 |
| Adjustable Care Life Inc. | 7 |
| Vitas Healthcare Corporation of California | 3 |
| Providence at Home With Compassus Hospice Care Orange County | 5 |
| Bristol Hospice-Orange County | 8 |
| Silverado Hospice Inc. | 16 |
| Bristol Hospice- Greater Los Angeles | 8 |
| Evergreen Hospice Care, Inc. | 5 |
| Five Star Home Hospice | 3 |
| Kaiser Foundation Hospital Anaheim Hospice | 2 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- CMS ended its Special Focus Program for hospices with serious problems on Feb 14, 2025, so no hospice is marked as one.
- Hospice quality measures have a gap from October 2025: CMS replaced its patient assessment then, and public results from the new one (HOPE) are expected around November 2027.
Sources
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Centers for Medicare & Medicaid Services, Hospice General Information (yc9t-dgbk).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Provider Data (252m-zfp9).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, CAHPS Hospice Survey (gxki-hrr8).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR hospice inspection reports (Hospice Survey Reports - Oct 2021 through Sep 2026.xlsx).
Released Oct 23, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice All Owners (e983965e-1603-4cb8-82b5-c40090e380d1).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Enrollments (25704213-e833-4b8b-9dbc-58dd17149209).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice ZIP Data (95rg-2usp).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Oct 27, 2026.
From the hospice
The public record above comes first. Anything the hospice adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospice will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospice”, and paying will never change a finding, a rating or the order of results.