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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609811
Report Date: 07/14/2022
Date Signed: 07/14/2022 03:21:32 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/18/2021 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20211118110648
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: 5DATE:
07/14/2022
UNANNOUNCEDTIME BEGAN:
12:23 PM
MET WITH:Roselin Finuliar - AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
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5
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7
8
9
Resident sustained an open wound while in care
INVESTIGATION FINDINGS:
1
2
3
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5
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9
10
11
12
13
Licensing Program Analyst (LPA) conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegation. LPA met with Roselin Finuliar and explained the reason for the visit.

LPA conducted physical plant tour at 12:45 PM, requested copies of facility documents relevant to the investigation at 1:00 PM.

Regarding the allegation that that resident sustained an opened wound while in care, it was alleged that Resident #1 (R1) was found with an open wound upon release from the hospital. LPA's record review on 07/15/22 at around 12:30 PM revealed that there was no indication that R1 had a wound prior to hospitalization on 11/06/21. LPA's interview with the administrator on 07/15/22 at 11:34 AM also revealed that it was her who saw the wound on R1 when R1 went back to the facility upon release from the hospital on 11/11/21 and reported it to the family member, CCL and primary care physician (PCP) and requested a wound care specialist to evaluate the wound. (continued on LIC 9099-C).

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20211118110648
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 07/14/2022
NARRATIVE
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32
(continued from LIC 9099)

Further record review also revealed that Home Health nurse only visited on 11/21/21 for a wound assessment and found that the injury was closed and that there was no need for a follow up evaluation.

Based on the information gathered during this and prior visits, there is insufficient evidence to support the allegation and therefore deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2