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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609813
Report Date: 09/08/2022
Date Signed: 09/08/2022 03:43:47 PM


Document Has Been Signed on 09/08/2022 03:43 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 1FACILITY NUMBER:
197609813
ADMINISTRATOR:ZAKHARYAN, TIGRANFACILITY TYPE:
740
ADDRESS:6624 SALE AVENUETELEPHONE:
(818) 704-6828
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:6CENSUS: 6DATE:
09/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Sona MuradayanTIME COMPLETED:
03:55 PM
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At 3:00 p.m. on 09/08/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with Administrator and disclosed the reason for the visit. An Incident Report was submitted regarding Resident #1 (R1) who was admitted to the hospital after their catheter came off and urine bag was filled with blood.

LPA conducted an interview the with Administrator at 3:10 p.m. and conducted a record review at 3:20 p.m.

No immediate health and safety concerns were observed. No deficiencies cited.

Exit interview conducted. Copy of report issued.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
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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