197609813-5-3-2022-31-AS-NRED-CE3QBH-20220503120133

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609813
Report Date: 05/03/2022
Date Signed: 05/03/2022 12:02:21 PM

Document Has Been Signed on 05/03/2022 12:02 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 1		FACILITY NUMBER:	197609813
ADMINISTRATOR:	ZAKHARYAN, TIGRAN		FACILITY TYPE:	740
ADDRESS:	6624 SALE AVENUE		TELEPHONE:	(818) 704-6828
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	6	CENSUS: 5	DATE:	05/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Sona Muradyan		TIME COMPLETED:	12:05 PM

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At 9:25 a.m. on 05/03/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. 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 06/30/2021 for an annual visit. It is a single story building with 6 bedrooms, 3 bathrooms, kitchen, office, common areas, and outdoor areas. It has an approved fire clearance for 6 residents, of which 5 may be non-ambulatory and 1 bedridden in bedroom #5. The facility serves residents with dementia. Approved hospice waivers for 6 residents.

Entry: At the main entrance, LPA observed signs for the facility’s visitation and handwashing policies. A posting for “No smoking – Oxygen in use” also hung at the front door. Once inside, LPA observed postings for confidential complaints, Ombudsman contacts, COVID signs, resident rights, resident right councils, neighborhood policy, license, and Administrator certificate.

Screening: LPA was screened for temperature and symptoms upon entry. Visitor log documented name and temperature. LPA advised on an additional column for symptom documentation.

Bedrooms: The facility has 6 bedrooms. 2 bedrooms are designated for staff. Staff rooms were free from hazards. Of the 4 resident bedrooms, 2 are private and 2 are shared. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. Bedroom #2 and Bedroom #1 contained Hoyer lifts and beds with half rails. Beds in the shared bedrooms were at least 6 feet apart. Shared bedrooms also had partitions. Bedroom #5 was being refurnished.

Bathrooms: The facility has 3 bathrooms. Staff and resident bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash cans with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At 10:20 a.m. LPA measured the water temperature in Bathroom #1 to be 105.7 degrees Fahrenheit.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

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 1	FACILITY NUMBER: 197609813
	VISIT DATE: 05/03/2022

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Kitchen: LPA observed an adequate supply of perishable and non-perishable food. All surfaces were sanitary. Sharp objects were locked. Medications were locked above the stove.

Laundry: LPA observed a washer and dryer in good condition. Detergent was locked above the appliances.

Common Areas: Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 10:31 a.m. LPA measured the room temperature to be 71.9 degrees Fahrenheit. LPA observed 2 storage closets by Bedroom #1 and the kitchen with sufficient clean linens.

Outdoor areas: LPA observed a covered patio area with seating in good condition. A ramp led out from the living room. The ramp was free from hazards. Hand rails were secure. An additional covered seating area was located on the side of the facility.

Safety: All emergency exit paths were free from obstructions. Exit doors and gates were unlocked. Emergency Disaster Plan posted at the front. Evacuation plans with routes labelled were posted throughout. 6 out of 6 auditory devices were on and functioning. The facility uses surveillance cameras inside and outside. At 10:35 a.m. LPA tested the smoke and carbon monoxide detector to be operational. The hallway fire door closed when the detector was tested. At 9:46 a.m. LPA observed a fully charged fire extinguisher near the kitchen. A receipt from 05/13/2021 was attached.

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

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: 05/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

LIC809 (FAS) - (06/04)

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