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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610244
Report Date: 03/10/2022
Date Signed: 03/10/2022 10:50:36 AM

Document Has Been Signed on 03/10/2022 10:50 AM - 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: 3DATE:
03/10/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Stasrr HernandezTIME COMPLETED:
10:55 AM
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At approximately 10:15 AM on 03/10/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced prelicensing inspection to verify deficiencies have been corrected. LPA met with Licensee and disclosed the reason for the visit.

Census: 3 residents

LPA was screened for temperature and symptoms of COVID-19. Staff prompted LPA to record information in a visitor log. The facility had signs relating to COVID-19 hung throughout.

Water temperature – On 03/08/2022, LPA measured water temperature to be over 120 degrees Fahrenheit. On 03/10/2022, LPA measured water temperature at 119.1 degrees Fahrenheit.

Refrigerator temperature – On 03/08/2022, LPA measured refrigerator temperature to be approximately 50 degrees Fahrenheit. On 03/10/2022, LPA measured refrigerator temperature at 30.7 degrees Fahrenheit.

Freezer temperature - On 03/08/2022, LPA measured freezer temperature to be approximately 10 degrees Fahrenheit. On 03/10/2022, LPA measured freezer temperature at -14.1 degrees Fahrenheit.

All deficiencies found during the 03/08/2022 prelicensing inspection have been corrected.

LPA conducted exit interview and issued a copy of the report.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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