197609812-7-28-2021-31-AS-MRUZ-C5CT6V-20210728142744

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609812
Report Date: 07/22/2021
Date Signed: 07/28/2021 02:29:06 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 3		FACILITY NUMBER:	197609812
ADMINISTRATOR:	SONA MURADYAN		FACILITY TYPE:	740
ADDRESS:	22600 KITTRIDGE STREET		TELEPHONE:	(818) 704-7733
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	6	CENSUS: 6	DATE:	07/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:42 PM
MET WITH:	Administrator - Sona Muradyan		TIME COMPLETED:	06:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 3:42 p.m. Licensing Program Analysts (LPAs) Melissa Ruiz, Angela Panushkina and Licensing Program Manager (LPM) Nichelle Gillyard conducted an unannounced annual inspection at the facility mentioned above. Team met with caregiver Martha Maria Reyna who granted access to the home. This is a 6-bedroom, 4-bathroom single story residence that includes a living room, dining area, kitchen, and dining area. LPA toured the entire facility with the Administrator Sona Muradyan who arrived at approximately 3:50 p.m. and observed the following: Infection control: LPA reviewed approved facility mitigation plan to make sure licensee was following current infection control recommendations. Upon arrival, the team was not screened by the caregiver and was not asked any infection control questions. Staff was unable to take LPAs temperatures. The team had to prompt and guide the caregiver through the screening process. Food Inspection: LPA conducted a food inspection tour. Currently the licensee has a offsite food waiver in which a outside food vendor provides meals for the residents. LPA observed there to be insufficient stock of one-week non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Smoke detectors were checked and are hardwired throughout the facility. Smoke detectors and carbon monoxide are observed to be operational.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

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 3	FACILITY NUMBER: 197609812
	VISIT DATE: 07/22/2021

NARRATIVE

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Resident rooms: There are 6 bedrooms designated for resident use and have sufficient lighting. One bedroom is designated for live-in staff. All bedrooms are properly furnished, cleaned and have appropriate bedding and linens. Auditory alarms are placed on each door. The facility has dementia residents in care.
Bathrooms: LPA toured resident bathrooms and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured at 117.3F. LPA observed appropriate hand washing signs posted in each bathroom, grab bars and non-skid mat. Towels and washcloths are not shared. Residents have sufficient amounts of supplies for personal hygiene which is provided by the Licensee. At 4:05 p.m. LPA observed cleaning products/chemicals accessible to residents.
Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. There are no bodies of water which is unsecured.
The garage is detached to the home and is kept locked inaccessible to clients.
Laundry service: There is enough linen available to change weekly or more if need.
Medications are in a centrally stored and locked.
Care and supervision: Team observed one staff to 6 residents on duty. One staff is tasked with providing care and supervision, which include by not limited to changing residents, assisting residents with toileting needs, assistance with medications, tranfers, etc. Staff are also tasked with screening visitor as they come into the facility. One staff is unable to meet all of these needs and keep any eye on everyone. A resident voiced a concerned that staff does not respond when needed at night after calling several times. Therefore additional staffing is needed.
Administrative: LPA collected the Administrators certification, Sample food menu and license from outside food vendor, certificate of liability insurance and LIC 500. Annual fees are current.

Deficiencies and Civil penalties were issued per CA code of Regulations Title 22 or Health and Safety Code. See 809D's included with this report.
Appeal rights issued.
Exit interview conducted.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC809 (FAS) - (06/04)

Page: 5 of 5

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 3	FACILITY NUMBER: 197609812
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(26)

87555 General Food Service Requirements (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above because the facility did not have enough non-perishible food for non-perishible foods which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/24/2021
	Plan of Correction
1 2 3 4	Administrator will go grocery shopping and provide the LPA a receipt of purchase.

Type A

Section Cited

CCR

874468.1(2)

87468.1 Personal Rights (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above due to the staff not following the infection control mitigation plan which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/24/2021
	Plan of Correction
1 2 3 4	Administrator shall provide in house training and provide training materials and proof of sign in sheet for staff to the LPA by e-mail.

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: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

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 3	FACILITY NUMBER: 197609812
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Cleaning agents and chemicals were found to be accesible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/24/2021
	Plan of Correction
1 2 3 4	Administrator will properly train staff to keep cleaning agents and chemicals inaccesible to residents and proof of training will be sent to LPA by e-mail.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC809 (FAS) - (06/04)

Page: 4 of 5

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 3	FACILITY NUMBER: 197609812
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(a)

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. One staff members was observed to take care of all 6 residents at once which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/29/2021
	Plan of Correction
1 2 3 4	Administrator agreed to look for additional care givers and notify CCLD of new hire.

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: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC809 (FAS) - (06/04)

Page: 2 of 5