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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610244
Report Date: 01/05/2022
Date Signed: 01/05/2022 02:57:22 PM

Document Has Been Signed on 01/05/2022 02:57 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:PEACEFUL KINGDOM HOME CARE IFACILITY NUMBER:
197610244
ADMINISTRATOR:PAREDES, VICTORIAFACILITY TYPE:
740
ADDRESS:17740 BALTAR ST.TELEPHONE:
(818) 339-3867
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 5DATE:
01/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:37 PM
MET WITH:Edith MenorTIME COMPLETED:
02:58 PM
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At approximately 2:37 PM on 01/05/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted a Case Management visit. LPA met with staff and disclosed the reason for the visit.

Census: 5

LPA was screened for COVID-19 symptoms at the front entry door.

LPA conducted a physical plant tour at approximately 2:41 PM. LPA met with all residents.

Exit interview conducted and report issued.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2022
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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