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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609811
Report Date: 06/05/2021
Date Signed: 06/05/2021 09:57:57 PM

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 6FACILITY NUMBER:
197609811
ADMINISTRATOR:ROSELIN FINULIARFACILITY TYPE:
740
ADDRESS:22626 KITTRIDGE STREETTELEPHONE:
(818) 884-2214
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:6CENSUS: 6DATE:
06/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
07:10 PM
MET WITH:Roseilin FinuliarTIME COMPLETED:
07:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yelena Avetisyan conducted an unannounced Case Management - Incident visit at the facility today in conjunction with a subsequent complaint visit of complaint control # 31-AS-20210121104029.

The purpose of this visit is to issued citation for absence of supervision observed by the LPA during the subsequent complaint visit. Upon arrival to the facility at 7:10 pm LPA met with staff Alan Kibombwe. LPA requested to speak with administrator. Staff stated that the administrator is across the street and asked if LPA would like for him to call her. LPA asked that administrator be called, however instead of calling the administrator via telephone staff member left the facility at 7:11 pm and walked across the street to call the administrator. For approximately 5 minutes the six residents of the facility were left without supervision. When staff returned at 7:16 pm LPA asked why staff did not use the phone to call the administrator. Staff stated that he left his phone at the facility when he went to talk to him earlier in the day. Per staff another caregiver was at the facility however when LPA asked to speak with the live in staff he did not open his door or respond.

At 7:19 pm Administrator Roselin Finuliar stated that she did not know why staff member would leave the facility and not call her, LPA explained that staff did not have his phone and administrator stated that he should have used the facility phone.

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited: (Refer to LIC 809-D).

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2021
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 6
FACILITY NUMBER: 197609811
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/05/2021
Section Cited

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Personnel-Operations. In each facility: When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement was not met as evidenced by:
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Based on observations made by the LPA the licensee/staff did not comply with the section cited above by leaving 6 out of 6 residents unsupervised when staff #1 (S1) left the facility to contact the administrator which posed an immediate health and safetu and personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2021
LIC809 (FAS) - (06/04)
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