197609814-5-3-2022-31-AS-NRED-CE3UHF-20220503153552

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609814
Report Date: 05/03/2022
Date Signed: 05/03/2022 03:36:22 PM

Document Has Been Signed on 05/03/2022 03:36 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 2		FACILITY NUMBER:	197609814
ADMINISTRATOR:	ZAKHARYAN, TIGRAN		FACILITY TYPE:	740
ADDRESS:	6636 SALE AVENUE		TELEPHONE:	(818) 704-9174
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	6	CENSUS: 6	DATE:	05/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Rosalyn Finuliar		TIME COMPLETED:	03:45 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

At 1:45 p.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 04/21/2022 for a Case Management visit. It is a single story building with 7 bedrooms, 5 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 bedridden in Bedroom #6. The facility serves residents with dementia. Approved hospice waivers for 6.

Entry: At the main entrance hung a sign stating “No Smoking – Oxygen in use”. Once inside, LPA observed postings for confidential complaints, Ombudsman contact information, resident rights, resident councils, neighborhood policy, administrator certificate, and the facility license.

Screening: LPA was screened for infectious disease upon entry. The screening station contained digital thermometer, hand sanitizer, and visitor log. LPA suggested adding two columns to track visitor symptoms and proof of vaccination.

Bedrooms: The facility has 7 bedrooms. 1 bedroom is designated for staff. It was locked and free from hazards. All 6 resident bedrooms are private. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition.

Bathrooms: The facility has 5 bathrooms. 4 bathrooms were private and 1 was a shared bathroom. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 3:28 p.m. LPA measured the water temperature in the shared bathroom 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)

Page: 1 of 2

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
	VISIT DATE: 05/03/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Kitchen: LPA observed an adequate supply of perishable and non-perishable food in refrigerators in the garage. The stove hood clean was free from debris. Appliances were in good condition. Sharps were locked in a drawer. Medications were locked above the counter.

Laundry: LPA observed a washing machine and a dryer in good condition. Detergents were locked near the appliances.

Common Areas: Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 2:30 p.m. LPA measured the room temperature to be 78.8 degrees Fahrenheit.

Safety: All emergency exit paths were free from obstructions. Exit gates were unlocked with self-closing latches. Emergency Disaster Plan was posted at the front. Evacuation routes were posted throughout. Auditory alarms were turned on and functioning. At approximately 2:15, smoke and carbon monoxide detectors were tested and operational. At approximately 2:30 p.m. LPA observed a fully charged fire extinguisher in the laundry area. A receipt from 05/13/2021 was attached.

Outdoor areas: LPA observed a covered patio area with furniture in good condition. A ramp led out to the street. It was free of hazards and had secure handrails.

Vehicle: The facility vehicel was parked in the driveway. It was operational and in good condition.

Garage: LPA observed cleaning supplies stored in the locked garage. Non-perishable food was stored separately.

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)

Page: 2 of 2