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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609813
Report Date: 11/15/2021
Date Signed: 11/18/2021 02:48:11 PM

Unfounded


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
11/12/2021 and conducted by Evaluator Eleza Jackson
COMPLAINT CONTROL NUMBER: 31-AS-20211112081945
FACILITY NAME:LAND OF PEACE 1FACILITY NUMBER:
197609813
ADMINISTRATOR:ZAKHARYAN, TIGRANFACILITY TYPE:
740
ADDRESS:6624 SALE AVENUETELEPHONE:
(818) 704-6828
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:6CENSUS: 5DATE:
11/15/2021
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Nona MuradyanTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident(s) in care sustained multiple pressure injuries.
Staff did not meet the incontinence needs of resident(s) in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
The visit was conducted on Monday, November 15, 2021, but due to a computer err LPA had to return Tuesday, November 12, 2021 for signatures.
Licensing Program Analyst Eleza Jackson conducted an unannounced complaint visit to investigate the allegations above. LPA met with the facility administrator and explained the reason for this visit.
Upon entry to the facility a physical plant tour was conducted at approximately 11:50am to ensure no immediate health and safety issues were present. LPA Jackson did not observe any immediate health and safety issues. LPA Jackson requested the following documents: staff roster, client roster, client daily activities chart, client wound care log, physicians report(s), appraisals for hospice clients. During the initial investigation it was determined that the above-named facility is not the facility in question. Regarding the allegations above a finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Report reviewed, signed and delivered. Exit interview conducted, no deficiencies cited.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Eleza JacksonTELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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