197609801-7-31-2022-31-AS-NRED-CGUTCC-20220731143632

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609801
Report Date: 07/31/2022
Date Signed: 07/31/2022 02:36:57 PM

Document Has Been Signed on 07/31/2022 02:36 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LAND OF PEACE 5		FACILITY NUMBER:	197609801
ADMINISTRATOR:	ROSELIN FINULIAR		FACILITY TYPE:	740
ADDRESS:	22625 KITTRIDGE STREET		TELEPHONE:	(818) 883-3356
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	6	CENSUS: 6	DATE:	07/31/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Tigran Zakharyan		TIME COMPLETED:	02:45 PM

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At 1:40 p.m. on 07/31/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out.

The facility was last visited on 07/23/2021 for an annual visit.

It is a single story building with 6 bedrooms, 3 bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 residents, of which 5 may be non-ambulatory and 1 may be bedridden in Bedroom #5. The facility serves residents with dementia. Approved hospice waivers for 6. The facility uses surveillance cameras inside and out.

Entry: Upon entry, LPA observed a maintained front yard. A posting for the facility’s visitation policy hung on the front door. LPA observed postings for ombudsman contact, confidential complaints, administrator certificate, facility license, Emergency Disaster Plan, resident rights, and resident councils.

Screening: LPA was screened for infectious disease upon entry. The screening station contained a digital thermometer and visitor log. LPA advised to include columns for symptoms and vaccination records in the visitor log.

Bedrooms: The facility has 6 bedrooms. 5 are private and 1 is shared. Bedroom #1 has a sign posted: Oxygen in use – No smoking. Staff was observed providing care for resident. Bedroom #3 is designated for staff. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. Evacuation routes were clearly labelled and posted in each room.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2022

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LAND OF PEACE 5	FACILITY NUMBER: 197609801
	VISIT DATE: 07/31/2022

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Bathrooms: The facility has 3 bathrooms. All bathrooms contained paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. Liquid soap is provided with each use due to residents with impulse control. At 2:01 p.m. LPA measured the water temperature in Bathroom #1 to be 105.0 degrees Fahrenheit.

Kitchen: LPA observed an adequate supply of perishable and non-perishable food. Sharps were locked near the stove. Medications were locked near the counter.

Laundry: LPA observed 2 functional appliances. Detergents were locked near the appliances.

Common Areas: Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. LPA observed linen closets in the hallways with sufficient fresh linens. Flashlights were available in the hallways as well.

Safety: All emergency exit paths were free from obstructions. Exit gates were unlocked. Emergency Disaster Plan posted. At 1:45 p.m. LPA tested the dual-functioning smoke and carbon monoxide detector to be operational. LPA observed a fully charged fire extinguisher in the kitchen with a receipt from 05/03/2022 attached. LPA detected 3 out of 3 auditory alarms functioning during visit.

Outdoor areas: LPA observed a covered patio with extra wheelchairs. The back yard was maintained.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2022

LIC809 (FAS) - (06/04)

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