197609814-7-9-2024-31-AS-NRED-D6ZV8D-20240709161235

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609814
Report Date: 07/09/2024
Date Signed: 07/09/2024 04:13:06 PM

Document Has Been Signed on 07/09/2024 04:13 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: 5	DATE:	07/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Sona Muradyan		TIME COMPLETED:	04:15 PM

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At 1:40 p.m. on 07/09/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the administrator designee and disclosed the reason for the visit.

The facility was last visited on 11/06/2023 for an annual inspection. It is a single story building with seven (07) bedrooms, five (05) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) residents, of which five (05) may be non-ambulatory and one (01) bedridden in Bedroom #6. The facility serves residents with dementia. Approved hospice waivers for six (06).

At the main entrance, LPA observed a visitor’s log, hand sanitizer, and postings for confidential complaint contacts, Ombudsman contact information, personal rights, rights of 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. 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, emergency water, and hygiene supplies were stored in the hallway cabinets. Cameras were used in common and exterior areas. At approximately 2:15 p.m., five (05) out of five (05) auditory alarms were tested and deemed operational.

All emergency exit paths were free from obstructions. The exit gate was unlocked with a self-closing latch. At approximately 2:30 p.m., the dual-purpose smoke and carbon monoxide detector in the hallway was 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.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

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: 07/09/2024

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The facility has seven (07) bedrooms. One (01) bedroom is designated for staff. The staff room was locked and free from hazards. All six (06) 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. Bedrooms #2, #3, #5, and #6 had oxygen in use and appropriate signage posted on the bedroom doors and at the exterior of the facility.

The facility has five (05) bathrooms. Four (04) bathrooms were private and one (01) is shared bathroom. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, grab bars near the toilet or commode, and a non-skid mat in the shower. At approximately 2:45 p.m. LPA measured the water temperature in the private bathroom to Bedroom #4 to be 107.9 degrees Fahrenheit.

LPA observed an adequate supply of perishable and non-perishable food in refrigerators, freezers, and pantries 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. Around 3:30 p.m. the house telephone was called and determined to be operational.

LPA observed a covered patio area with furniture in good condition. A ramp with a sturdy handrail led out to the exit. A gardening area was available in the rear of the facility. A gas grill was also present. At approximately 4:00 p.m. a fully charged fire extinguisher was observed in the laundry area. It was last inspected on 03/24/24.

During today's inspection, the facility is in compliance with Title 22 regulations. No immediate health or safety hazards were noted at the time of the visit.

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: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC809 (FAS) - (06/04)

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