197609812-11-8-2023-31-AS-NRED-CXDW2F-20231108155417

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609812
Report Date: 11/08/2023
Date Signed: 11/08/2023 03:54:24 PM

Document Has Been Signed on 11/08/2023 03:54 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
WOODLAND HILLS S.ASC, 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:	11/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Sona Muradyan		TIME COMPLETED:	03:55 PM

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At 11:00 a.m. on 1108/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with the Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out at 11:15 a.m. No immediate health or safety hazards were observed at the time of this visit.

A file review was conducted at 9:30 a.m. today prior to the visit.

The facility was last visited on 03/20/2023 for a complaint visit. It is a single story building with 6 bedrooms, 4 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 #6. The facility serves residents with dementia. Approved hospice waivers for 6 residents.

The front yard was well maintained. LPA signed in on the visitor log. Staff took LPA’s temperature upon entry. Near the dining room table were postings for resident rights, rights of resident councils, Ombudsman contact, confidential complaints, emergency disaster plan, house rules, neighborhood grievance policy, non-discrimination notice, visitation policy, administrator certificates, and the facility license.

The facility has 6 bedrooms. 5 are private and 1 is shared. One private bedroom is designated for staff. The staff bedroom was locked and free of hazards. All bedrooms contained a night stand, storage, and bed with adequate bedding. Five (05) out of six (06) bedrooms contained a chair. The chair in Bedroom #2 was removed per the resident’s preference. All furnishings were clean and in good condition. Emergency evacuation routes were posted in each room and clearly labelled.

The facility has 4 bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can, grab bars near the toilet, shower, and commode, and a non-skid mat in the shower. At 11:40 a.m. LPA measured the water temperature in the bathroom between Bedroom #2 and Bedroom #3 to be 107.1 degrees Fahrenheit.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LAND OF PEACE 3	FACILITY NUMBER: 197609812
	VISIT DATE: 11/08/2023

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LPA observed an adequate supply of perishable and non-perishable food in the kitchen and garage refrigerators and freezers. The stove hood was clean. Medications were locked by the refrigerator. Sharp objects were locked under the counter top.

A washer and dryer in good condition near the dining room. Detergents and cleaners were locked in the bathroom closest to the dining room. At 11:45 a.m. LPA observed a fully charged fire extinguisher near the laundry area. It had a receipt taped to it from 05/03/2022.

Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. A fireplace was appropriately screened. The house telephone was called and determined functional at 11:50 p.m. Activities, reading material, television and art supplies were observed in the living room.

All emergency exit paths were free from obstructions. Three (03) out of three (03) exit gates were unlocked. A ramp with secure hand rails led out from Bedroom #6. At 2:45 p.m. the administrator tested the smoke and carbon monoxide detector to be operational. When tested, three (03) out of three (03) alarms functioned and two (02) out of two (02) fire doors closed automatically.

A resident was visiting with family in the covered patio area. Furniture was in good condition. The back yard was maintained. The back yard contained a fountain with no water. A detached unit was locked.

LPA reviewed staff and resident files at 12:30 p.m. LPA, administrator, and staff conducted a medication review at 2:50 p.m. LPA interviewed staff and residents at 3:15 p.m.

During today's inspection, the facility is in compliance with Title 22 regulations.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

LIC809 (FAS) - (06/04)

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