197609815-7-31-2022-31-AS-NRED-CGUS3M-20220731133123

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609815
Report Date: 07/31/2022
Date Signed: 07/31/2022 01:31:53 PM

Document Has Been Signed on 07/31/2022 01:31 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 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:	07/31/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Cecilia Tembo		TIME COMPLETED:	01:35 PM

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At 10:55 a.m. on 07/31/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with staff and later Administrator and disclosed the reason for the visit. LPA and staff toured the facility inside and out.

The facility was last visited on 07/23/2021 for an annual visit. It is a single story building with 6 bedrooms, 3 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 may be bedridden in Bedroom #6. The facility serves residents with dementia. Approved hospice waivers for 6. The facility uses surveillance cameras on the interior.

Entry: LPA observed a maintained front yard. The facility’s visitation and COVID policies were hung on the front door.

Screening: LPA was screened for infectious disease upon entry. The screening station contained visitor log, hand sanitizer, and digital thermometer. LPA advised to create two additional columns in the visitor log to record symptoms and vaccination status of visitors. LPA postings for Ombudsman contact, confidential complaints, resident rights, administrator certificates, facility license, facility sketch, and COVID policies.

Bedrooms: The facility has 6 bedrooms. 5 are private. 1 is shared. Bedroom #1 is designated for staff. LPA observed no hazards in the staff bedroom. Bedroom #2 had a sign hung on the door: Oxygen in use – No smoking. LPA observed an oxygen tank, full bedrails, and a mat by the bed. Staff confirmed the mat is a safety measure when the resident independently gets out of bed. Bedroom #3 contained a Hoyer lift. Bedroom #4 is a shared bedroom. One resident was observed watching television and stated they liked the facility. Bedroom #5 was unoccupied. Bedroom #6 contained a private bathroom. The auditory alarm for the sliding door was detected at approximately 11:35 a.m. A resident was watching television in the bedroom. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2022

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: 07/31/2022

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Bathrooms: The facility has 3 bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the shower, and a non-skid mat in the shower. Bathroom #1 is designated for staff and visitors. Bathroom #2 contained 2 showers with shower seats in each. At approximately 11:25 a.m. LPA observed a broken toilet paper holder, a broken faucet, and no grab bars around the toilet. Staff informed LPA the tap was turned off and the other tap next to it is functional. At 11:27 a.m. LPA measured the water temperature in Bathroom #1 to be 106.2 degrees Fahrenheit.

Kitchen: LPA observed an adequate supply of perishable and non-perishable food. Appliances were functional. Sharps were locked by the stove. Medications were locked near the refrigerator. Staff was observed preparing food for lunch at approximately 11:40 p.m.

Laundry: LPA observed a functional washer and dryer in the laundry area. Detergents were locked above the appliances. A fully charged fire extinguisher hung on the wall near the appliances. A receipt from 05/03/2022 was attached to the fire extinguisher.

Common Areas: Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 11:50 a.m. LPA measured the room temperature to be 79.8 degrees Fahrenheit.

Safety: All emergency exit paths were free from obstructions. Exit gates were unlocked. Emergency Disaster Plan posted at the front. Facility sketch with evacuation routes was posted throughout the facility. At 1:15 p.m. LPA tested the dual-function smoke and carbon monoxide detector to be operational. At approximately 11:55 a.m. LPA detected 5 out of 5 auditory alarms functioning.

Outdoor areas: LPA observed a covered patio with furniture in good repair. The back yard was maintained.

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: 07/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2022

LIC809 (FAS) - (06/04)

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