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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610244
Report Date: 02/08/2022
Date Signed: 02/08/2022 02:35:38 PM

Document Has Been Signed on 02/08/2022 02:35 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:
02/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Vicky ParedesTIME COMPLETED:
02:35 PM
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At 1:15 PM on 02/08/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with Administrator and disclosed the reason for the visit.

LPA conducted a physical plant tour at 1:20 PM. LPA heard 4 out of 5 auditory alarms functioning. LPA advised Administrator to acquire a functioning alarm for the back exit by the laundry room.

LPA viewed adequate fresh food in the refrigerator and freezer. A pair of scissors were dirty and in the sink. LPA advised staff and Administrator to lock up all sharp objects.

A resident with dementia walked around the facility, and staff told resident to sit down two times. Staff provided redirection back to the couch after two minutes of the resident walking around.

Administrator noted nurse and Licensee were at the facility 30 minutes before LPA arrival. Administrator recommended future staff training with Hoyer Lift, oxygen, and repositioning. LPA agreed.

LPA spoke with 4 out of 5 residents in care. All residents reported doing well, and one reported coming from outdoor exercise and lunch.

LPA conducted exit interview and issued report.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2022
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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