197609815-7-28-2021-31-AS-MRUZ-C5CT99-20210728143134

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609815
Report Date: 07/23/2021
Date Signed: 07/28/2021 02:32:41 PM

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 4		FACILITY NUMBER:	197609815
ADMINISTRATOR:	SONA MURADYAN		FACILITY TYPE:	740
ADDRESS:	22615 KITTRIDGE STREET		TELEPHONE:	(818) 704-4204
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	6	CENSUS: 5	DATE:	07/23/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Administrator - Sona Muradyan		TIME COMPLETED:	03:30 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 11:25 a.m. Licensing Program Analyst Melissa Ruiz conducted an unannounced annual inspection at the facility mentioned above. LPA met with caregiver Mwangala Liswaniso who granted access to the home. This is a 6-bedroom, 3-bathroom single story residence that includes a living room, kitchen, and dining area. LPA toured the entire facility with the Administrator Sona Muradyan who arrived at approximately 11:35 a.m. and observed the following: Infection control: LPA reviewed approved facility mitigation plan to make sure licensee was following current infection control recommendations. Upon arrival, LPA was screened by the caregiver, and was asked to sign-in the visitors log. Staff also took LPA's temperature. Physical Plant:The facility has dementia residents in care. Auditory alarms are placed on each door. Smoke detectors are hardwired throughout the facility. Smoke detectors and carbon monoxide were observed to be operational at 12:00 p.m. The facility has a fire extinguisher and the date of purchase is 05/13/21. The facility maintains a comfortable temperature of 78 degrees. Food Inspection: LPA conducted a food inspection tour. Currently the licensee has an off-site food waiver in which an outside food vendor provides meals for the residents. LPA observed frozen foods properly wrapped and stored appropriately Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Facility has an adequate supply of perishable and non-perishable food supply. Resident rooms: There are five (5) bedrooms designated for resident use and have sufficient lighting. One (1) bedroom is designated for live-in staff. All bedrooms are properly furnished, cleaned and have appropriate bedding and linens. Auditory alarms are placed on each door. . Bathrooms: LPA toured resident bathrooms and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured at 118.6F at 12:00 p.m. LPA observed appropriate hand washing signs posted in each bathroom, grab bars and non-skid mat. Towels and washcloths are not shared. Residents have sufficient amounts of supplies for personal hygiene which is provided by the Licensee.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LAND OF PEACE 4	FACILITY NUMBER: 197609815
	VISIT DATE: 07/23/2021

NARRATIVE

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Laundry service: There is enough linen available to change weekly or more if need.

Medications are in a centrally stored and locked.

Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. There are no bodies of water.

Administrative: LPA collected a sample food menu, certificate of liability insurance and LIC 500. Annual fees are current.

Exit interview conducted.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

LIC809 (FAS) - (06/04)

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