197609815-7-26-2024-31-AS-NRED-D7JVW6-20240726164725

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609815
Report Date: 07/26/2024
Date Signed: 07/26/2024 04:47:47 PM

Document Has Been Signed on 07/26/2024 04:47 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 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: 6	DATE:	07/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Sona Muradyan		TIME COMPLETED:	04:50 PM

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At 1:05 p.m. on 07/26/24, 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.

The facility was last visited on 07/31/22 for an annual visit. It is a single story building with six (06) bedrooms, three (03) 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).

The front yard was maintained. At the main entrance, LPA observed postings for the activity calendar, resident rights, rights of resident councils, Ombudsman contact, confidential complaints, emergency disaster plan, house rules, neighborhood grievance policy, non-discrimination notice, visitation policy, administrator certificates, COVID precautions, facility sketch, and the facility license. A screening station contained a sign-in sheet, digital thermometer, and masks.

The facility has six (06) bedrooms. One (01) bedroom is designated for staff. The staff bedroom was free of hazards. All bedrooms contained a night stand, lamp, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. Emergency evacuation routes were posted in each room and clearly labelled.

The facility has three (03) bathrooms. All resident bathrooms contained liquid soap, paper towels, trash cans, grab bars near the toilet, shower, and commode, and a non-skid mat in the shower. At 3:15 p.m. LPA measured the water temperature in the shared bathroom 109.8 degrees Fahrenheit.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

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 4	FACILITY NUMBER: 197609815
	VISIT DATE: 07/26/2024

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LPA observed an adequate supply of perishable and non-perishable food in the kitchen and garage refrigerators and freezers. The stove hood was clean. Medications were locked by the refrigerator. Sharp objects were locked under the counter top and near the refrigerator. A washer and dryer in good condition near the kitchen. Detergents and cleaners were locked above the appliances. At 3:30 p.m. LPA observed a fully charged fire extinguisher near the laundry area. It was last inspected on 03/28/24.

All emergency exit paths were free from obstructions. The exit gate was unlocked. Ramps with secure hand rails led out from Bedroom #5 and a sliding glass door near the living room. At 3:45 p.m. the administrator tested the smoke and carbon monoxide detector to be operational.

The covered patio area contained furniture was in good condition. The back yard was maintained and contained a garden area. The garage was locked and contained extra supplies.

Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. A fireplace was appropriately covered. The hallway closet contained an adequate supply of fresh linens and towels. The room temperature was measured to be 77 degrees Fahrenheit at 3:50 p.m. The house telephone was called and determined functional at 3:55 p.m. Activities, reading material, television, a piano, and art supplies were observed in the living room.

During today's inspection, the facility is in compliance with Title 22 regulations. No immediate health and safety risks were observed during today’s 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: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

LIC809 (FAS) - (06/04)

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