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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610244
Report Date: 05/31/2024
Date Signed: 05/31/2024 02:08:13 PM

Document Has Been Signed on 05/31/2024 02:08 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PEACEFUL KINGDOM HOME CARE IFACILITY NUMBER:
197610244
ADMINISTRATOR/
DIRECTOR:		PAREDES, VICTORIAFACILITY TYPE:
740
ADDRESS:17740 BALTAR ST.TELEPHONE:
(818) 339-3867
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 6DATE:
05/31/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Maria Victoria Paredes, DesigneeTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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At 9:00 AM, Licensing Program Manager, (LPM) Nichelle Gilyard, and Licensing Program Analyst, (LPA) Huma Rahimi, conducted an unannounced Plan of Correction (POC) visit.
LPM and LPA met with the staff Jaizel Mabuti. The Administrator Jose Hernandez was contacted via telephone and explained the reason for the visit. Facility designee Maria Victoria Paredes appeared to assist with the visit and to accept the report.

The purpose of the plan of correction visit to make sure deficiencies from annual visit dated May 11, 2024, and Case management visit May 22, 2024, were corrected.

Entrance interview conducted.

Case management visit- May 22, 2024:
1. Plan of correction met. Incident report for May 11, 2024, was emailed to LPA by the due date, however Incident report for May 19, 2024, in regard to a hospitalization was not submitted to CCL. It is now more than 7 days a new citation and civil penalty will be issued.
Annual visit- May 11, 2024- The following is not cleared:
1. 87303 ( e)(5)-LPA toured facility hall bathroom, next to room #3. No non-skid mat observed in the shower. This is posses a potential slip and fall hazard to the resident in care. Plan of correction not met.
2. 1569.625(b)(2)- LPA reviewed staff records. No training presented. Plan of correct not met.
3. 1569.625(b)(1)- LPA reviewed staff records. No training presented. Plan of correction not met.
4. 87458(a)- LPA reviewed resident records. No updated Physicians report for R2/R3. Plan of correction not met.
5. 87506(b)- LPA reviewed resident records. While the Admissions agreement was complete for R2, the appraisal for R3 was not completed. Plan of correction not met.
Continue on LIC 809C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PEACEFUL KINGDOM HOME CARE I
FACILITY NUMBER: 197610244
VISIT DATE: 05/31/2024
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6. 87458(b)(1)- LPA reviewed resident records. No TB clearance for R1/R2. Plan of correction not met.
7. 1569.695(c)- LPA reviewed and requested documentation for updated emergency disaster drill. No documentation presented. Plan of correction not met.
8. 87608(a)(5)(A)- LPA did not observe any documentation for full bed rails from the doctor for R1. Plan of correction not met.
9. 87355(e)(3)- LPA did not observe that S3 is associated to the facility. Plan of correction not met because the plan of correction was not cleared within 10 working days by the department it shall be recited.

Observations:
1. While waiting for facility designee LPA Rahimi checked staff for criminal records, staff # 3 is not associated with the facility. LPA observed transfer request form in file. However, staff was not associated. Citation issued.
2. During physical plant tour the Long-Term Care Ombudsman and Community Care Licensing Complaint posters were posted at the main entrance behind the propped open front door. Staff moved the posters during the visit.
3. LPA/LPM observed there to be insufficient supply of 7-day non-perishable foods. Licensee shall go to the store and purchase a sufficient supply of 7-day non-perishable food. Submit a receipt to LPA by 06/03/2024. 4. LPA/LPM observed the stove top and tea kettle to have a build up of grease which needs to be clean. Staff is working to clean up the stove during the visit.
5. LPA/LPM observed what appeared to be a build up of rusted mold by the sink area in the kitchen. The licensee shall remove and clean the rusted mold behind the kitchen sink. The Licensee shall submit a photo to LPA by 06/03/2024.
6. LPA/LPM observed staining on bedding in room #2. Also designated Exit door in the room was stuck and hard to open. This needs to be addressed this is a health and safety issue. The bedding was replaced during visit. The licensee shall submit proof that the door was repaired and no longer sticks due by 06/03/2024.
7. LPA conducted a file review for the Administrator. The following is missing: First Aid/CPR. The Administrator shall submit a training certificate of First Aid/CPR to LPA by 06/03/2024.
8. May 19th incident involving R2’s hospitalization was not submitted w/7days of the incident to CCL. Citation issued/civil penalty issued. Due by 05/31/2024.
9. LPA/LPM did not observe completed Hospice and Home Health files, no plan of care or notes maintained. Due by 06/03/2024.
Continue on LIC 809C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PEACEFUL KINGDOM HOME CARE I
FACILITY NUMBER: 197610244
VISIT DATE: 05/31/2024
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10. Fees were due April 25, 2024. Amount of $742 is due immediately. LPA left information of the amount and the pin number with the designee. Due 05/31/2024.
11. Documentation on Jose Hernandez, the Administrator was not received. The licensee is to immediately submit LIC 500, LIC 501, LIC 503, LIC 508, Finger Print Clearance, 1st Aid/CPR, Copy of the Administrator certificate, and LIC 308 designation of facility responsibility naming Jose Hernandez as the Administrator, and Board resolution naming Jose Hernandez as the Administrator of the facility. Due by 06/03/2024.
12. Based on the plan of correction visit, the administrator failed to submit corrections to the department by the required due date, and it appears that the Administrator lacks the knowledge of licensing rules and regulations. Citation issued.

Plans of corrections letters were issued for deficiencies cleared today.

LPA explained report and civil penalties to the Administrator over the phone. LPA left a copy of the report. Additional citations and civil penalties were issued during this visit. Appeal rights given and exit interview conducted.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/31/2024 02:08 PM - It Cannot Be Edited


Created By: Huma Rahimi On 05/31/2024 at 12:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PEACEFUL KINGDOM HOME CARE I
FACILITY NUMBER: 197610244

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2024
Section Cited
CCR
87355(e)(3)

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Criminal Record Clearance-(e) All individuals subject to a criminal record review.... (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
This requirement is not met as evidenced by:
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Administrator will associate S3 to the facility by POC due date 06/03/24 and submit a copy of guardian's roster to the department by POC due date 06/03/24. Or submit LIC 9182 transfer request form and a clear copy S3 Identification to CCL for association.
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 3 staff is not associate to the facility, S3 was not associated to the facility and has been working at the facility since 5/10/24 which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
05/31/2024
Section Cited
CCR87211(a)(1)A,B&D

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Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)...
This requirement is not met as evidenced by:
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Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. R1's incident report shall be submitted to LPA by POC date.
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Based on record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding R1's hospitalization on 05/19/24, which poses a potential health and safety risk to persons in care.
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Second citation within 12 months. Civil Penalty issued.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Huma Rahimi
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/31/2024 02:08 PM - It Cannot Be Edited


Created By: Huma Rahimi On 05/31/2024 at 01:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PEACEFUL KINGDOM HOME CARE I
FACILITY NUMBER: 197610244

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2024
Section Cited
CCR
87405(d)(1,2)

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Administrator Qualifications - 87405 (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator... (1) Knowledge of the requirements...
This requirement is not met as evidenced by:
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Administrator agrees to review and complete all deficiencies and other concerns indicated in this report and the annual visit from 05/11/2024. The Administrator shall submit all corrections to the department.
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Based on the plan of correction visit, the administrator failed to submit corrections to the department by the required due date, and it appears that the Administrator lacks the knowledge of licensing rules and regulations which poses an immediate health and safety risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Huma Rahimi
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024


LIC809 (FAS) - (06/04)
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