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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609814
Report Date: 04/21/2022
Date Signed: 04/21/2022 11:15:45 AM


Document Has Been Signed on 04/21/2022 11:15 AM - 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 2FACILITY NUMBER:
197609814
ADMINISTRATOR:ZAKHARYAN, TIGRANFACILITY TYPE:
740
ADDRESS:6636 SALE AVENUETELEPHONE:
(818) 704-9174
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:6CENSUS: 6DATE:
04/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Tigran ZakharyanTIME COMPLETED:
11:25 AM
NARRATIVE
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At approximately 10:15 a.m. on 04/21/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and later Administrator and disclosed the reason for the visit.

On 04/18/2022, the facility submitted an incident report regarding Resident #1 (R1). It was reported that at 2:55 a.m. on 04/17/2022, West Hills Hospital notified the facility that R1 was seen unsupervised outside of the facility. R1 was held at the hospital for observation until 04/18. At the time of the incident, facility staff was tending to other residents and did not any hear auditory devices. A power outage occurred on 04/15/22 which may have caused the alarms to malfunction.

At 10:25 a.m. staff and LPA tested auditory devices. LPA heard 5 out of 5 auditory alarms on and functioning at the front door, laundry room, family room, hall door, and Bedroom 7 door where R1 stayed. Staff held a conversation with R1. R1 was safe and in good health.

At approximately 10:35 a.m. Administrator confirmed that the facility currently serves residents with Dementia. Administrator also attributed the AWOL to the power outage on 04/15.

During today's inspection, the facility is in compliance with Title 22 regulations. Deficiency issued for auditory devices turned off on 04/17 on the attached LIC 809-D page.

Exit interview conducted. Copy of report provided. Appeal rights provided. Citation issued.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
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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Document Has Been Signed on 04/21/2022 11:15 AM - It Cannot Be Edited

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 2
FACILITY NUMBER: 197609814

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2022
Section Cited

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87705 Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
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Based on record review and interview, the licensee did not ensure 1 out of 5 auditory devices was functioning properly on 04/17/2022 which poses a potential Health, Safety, and Personal Rights risk to residents in care.
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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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
LIC809 (FAS) - (06/04)
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