197609811-7-31-2022-31-AS-NRED-CGUUS5-20220731154947

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609811
Report Date: 07/31/2022
Date Signed: 07/31/2022 03:50:11 PM

Document Has Been Signed on 07/31/2022 03:50 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 6		FACILITY NUMBER:	197609811
ADMINISTRATOR:	ROSELIN FINULIAR		FACILITY TYPE:	740
ADDRESS:	22626 KITTRIDGE STREET		TELEPHONE:	(818) 884-2214
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:	02:50 PM
MET WITH:	Tigran Zakharyan		TIME COMPLETED:	03:55 PM

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At 2:50 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 07/14/2022 for a complaint visit.

It is a single story building with 6 bedrooms, 3 bathrooms, kitchen, 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 on the exterior and interior.

Entry: Upon entry, LPA observed posting for facility’s visitation policy. The front yard was maintained.

Screening: LPA was screened for infectious disease upon entry. The screening station contained visitor log, hand sanitizer, and digital thermometer. Visitor log tracked contact tracing information, temperature, symptoms, and vaccination status.

Bedrooms: The facility has 6 bedrooms. 5 are private and 1 is shared. Bedroom #2 is designated for staff. No hazardous objects were present. Bedroom #3 is shared. Beds were at least 6 feet apart for social distancing. Bedroom #4 contained a bed with full bed rails. Bedroom #5 contained a bedridden resident. The exit was unlocked and free of obstructions. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition.

Bathrooms: The facility has 3 bathrooms. All bathrooms contained liquid soap, 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. Bathroom #1 contained two showers in good condition. At 2:55 p.m. LPA measured the water temperature in Bathroom #1 to be 114.6 degrees Fahrenheit.

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 6	FACILITY NUMBER: 197609811
	VISIT DATE: 07/31/2022

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Kitchen: LPA observed an adequate supply of perishable and non-perishable food. The stove and hood were clean. Sharps were locked by the stove. Medications were locked above the counter top.

Laundry: LPA observed a dryer and washer in good condition. Detergents were locked. A fully-charged fire extinguisher was located near the laundry room. A receipt from 05/03/2022 was attached to the extinguisher.

Common Areas: Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 3:21 p.m. LPA measured the room temperature to be 76.4 degrees Fahrenheit. LPA observed board games, casino games, and activities in the dining room. Seating was arranged to accommodate social distancing.

Safety: All emergency exit paths were free from obstructions. All exits were unlocked. Emergency Disaster Plan posted at the front. Evacuation routes clearly labelled and posted in each bedroom. Fire sprinklers located throughout the facility. 5 out of 5 auditory alarms were detected during the visit.

Outdoor areas: LPA observed a covered patio area outside of Bedroom #6. All handrails were secure. 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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