197609814-11-7-2023-31-AS-NRED-CXD2NJ-20231107163248

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609814
Report Date: 11/07/2023
Date Signed: 11/07/2023 04:32:53 PM

Document Has Been Signed on 11/07/2023 04:32 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
WOODLAND HILLS S.ASC, 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:	11/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Tigran Zakharyan		TIME COMPLETED:	04:32 PM

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At 10:00 a.m. on 11/07/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out at 10:15 a.m. No immediate health or safety hazards were noted at the time of the visit.

The facility was last visited on 05/03/2022 for an annual inspection. 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.

At the main entrance, LPA observed postings for confidential complaint contacts, Ombudsman contact information, resident rights, resident councils, neighborhood policy, house rules, facility sketch with evacuation routes clearly labelled, emergency disaster plan, admission agreement, administrator certificate, and the facility license.

Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. The interior was recently painted. Two (02) residents were observed watching television in the living room. A piano, reading material, and activities were available in the living room as well. Sufficient amounts of fresh linens and hygiene supplies were stored in the hallway cabinets.

The facility has 7 bedrooms. 1 bedroom is designated for staff. The staff room 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. Bedroom #6 had a resident using oxygen. Appropriate signage was posted on the bedroom door and at the exterior of the facility.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LAND OF PEACE 2	FACILITY NUMBER: 197609814
	VISIT DATE: 11/07/2023

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The facility has 5 bathrooms. 4 bathrooms were private and 1 was a shared bathroom. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, grab bars near the toilet, commode, and shower, and a non-skid mat in the shower. At approximately 10:45 a.m. LPA measured the water temperature in the shared bathroom to be 115.7 degrees Fahrenheit.

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

LPA observed a washing machine and a dryer in good condition in the laundry area. Detergents were locked near the appliances. The administrator stated the dryer was serviced yesterday, 11/06/2023.

LPA observed a resident sitting in 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. A gardening area was available in the rear of the facility. A gas grill was also present.

All emergency exit paths were free from obstructions. The exit gate was unlocked. All auditory alarms were on and functioning. At approximately 11:00 a.m., the dual-purpose smoke and carbon monoxide detector were tested and operational. When tested, three (03) out of three (03) detectors were heard and the fire door in the living room released from its magnetic suspension. At approximately 12:30 p.m. a fully charged fire extinguisher was observed in the laundry area. A receipt from 05/03/2022 was attached.

The facility vehicle was parked in the driveway. Seat belts, windows, and ignition were operational and in good condition. LPA observed cleaning supplies stored in the locked garage. Perishable and non-perishable food were stored separately.

LPA conducted resident and staff interviews between 11:30 a.m. and 12:15 p.m., a medication review with staff at 12:30 p.m., and reviewed staff and resident files at 3:30 p.m.

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

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

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