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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610244
Report Date: 05/11/2024
Date Signed: 05/11/2024 02:11:48 PM

Document Has Been Signed on 05/11/2024 02:11 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
Lookup Error,
, CA
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: 3DATE:
05/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:31 AM
MET WITH:Gliceria Mabuti - CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Gliceria Mabuti and explained the reason for the visit.

The facility is licensed to serve 6 residents over the age of 60 years old, of which 6 may be bedridden, with a hospice waiver for 3. Facility currently is serving (3) residents on hospice. Facility is located in a residential area and consist of a single home with 6 bedrooms and 3 bathrooms, a dining room, a living, room, a family room, a kitchen, a front yard, and back yard.

LPA Flores conducted a tour with Jaizel Mabuti - Caregiver and observed the following:
Facility is in good repair inside and outside. Kitchen was observed clean and sufficient food for at least 2 days of perishables and 7 days of non-perishables were observed. Medication and sharps were observed locked in kitchen cabinets. Laundry area is clean and cleaning supplies were observed locked. Five (5) Resident rooms were observed with sufficient lighting, the required furniture and bedding supplies. Half bed rails were observed on room #5 and #6 and full bed rails were observed on room #3 in resident's beds. Room #4 was not observed as it is currently being used as a staff room. Three (3) Bathrooms were observed clean and in good repair. Bathroom #3 in room #6 was observed without a skid mat/strips. Water temperature was tested in each bathroom and tested between 115.5 - 117.8 degrees F., which is within the required 105-120 degrees F. Facility has a sound devices in each exit door which are in working condition. Smoke/Carbon monoxide detectors were tested and are in working condition, detector in room #3 had a faint noise. Fire extinguisher was observed by the kitchen and was last checked on 12/9/23. Backyard and front yard are clean and have a seating area. PUB 475 or Local Ombudsman posters were posted behind the entry door at the facility.

LPA reviewed medication for 2 residents, and files for 3 residents. (CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2024
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 15
Document Has Been Signed on 05/11/2024 02:11 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/11/2024 at 12:02 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
,
, CA

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
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.
POC Due Date: 05/12/2024
Plan of Correction
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2
3
4
Administrator will associate S3 to the facility by POC due date 5/12/24 and submit a copy of guardian's roster to the department by POC due date 5/12/24.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2024


LIC809 (FAS) - (06/04)
Page: 2 of 15
Document Has Been Signed on 05/11/2024 02:11 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/11/2024 at 12:02 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
,
, CA

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on record review, the licensee did not comply with the section cited above in 1 out 3 staff does not have a TB clearance, S3 does not have TB clearance on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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2
3
4
Adminsitrator will ensure S3 obtains a TB clerance and submits a copy to the department by POC due date 5/17/24.

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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2024


LIC809 (FAS) - (06/04)
Page: 3 of 15
Document Has Been Signed on 05/11/2024 02:11 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/11/2024 at 12:02 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
,
, CA

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 3 bathrooms observed, bathroom #3 in room #6 does not have a skid mat which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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2
3
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Administrator will provide a skid mat/strips in the shower and submit a picture to the department by POC due date 5/17/24.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in S4 who relieves staff on duty does not have a copy of first aid/CPR on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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3
4
Administrator will ensure S4 takes CPR/First aid trianing and submits a copy to the department by POC due date 5/17/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2024


LIC809 (FAS) - (06/04)
Page: 4 of 15
Document Has Been Signed on 05/11/2024 02:11 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/11/2024 at 12:02 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
,
, CA

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in administrator's file was not available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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Administrator will certify that will ensure file is maintain at the facility for review and a copy of file should be submitted to the department by POC due date 5/17/24.
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in S3 does not have a health screening on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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2
3
4
Administrator will provide a copy of S3's health screening to the department by POC due date 5/17/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2024


LIC809 (FAS) - (06/04)
Page: 5 of 15
Document Has Been Signed on 05/11/2024 02:11 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/11/2024 at 12:02 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
,
, CA

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 out of 3 staff do not have initial hours of training on file for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
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Administrator will provide initial 40 hours of training to staff and will provide a copy of topics, duration of each, and signature to acknowledge training was receive to the department by POC due date 5/17/24.

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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2024


LIC809 (FAS) - (06/04)
Page: 6 of 15
Document Has Been Signed on 05/11/2024 02:11 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/11/2024 at 12:02 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
,
, CA

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of 3 staff have received 8 hours of training within the last 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
1
2
3
4
Administrator will provide additional hours of training in the topics above by a skilled proffessional to meet the 20 hours of annual training and submit a copy to the department by POC due date 5/17/24.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2024


LIC809 (FAS) - (06/04)
Page: 7 of 15
Document Has Been Signed on 05/11/2024 02:11 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/11/2024 at 12:02 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
,
, CA

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of 3 residents, R2 does not have an admission agreement and R3's appraisal needs to be update on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
1
2
3
4
Administrator will submit a copy of admission agreement for R2 and a copy of updated appraissal for R3 to the department by POC due date 5/17/24.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 ouf of 3 residents, R2 does not have an initial physician's report on file, and R3's last physician's report was dated 2/22/22 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
1
2
3
4
Administrator will submit a copy of physician's reports for R2 and R3 to the department by POC due date 5/17/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2024


LIC809 (FAS) - (06/04)
Page: 8 of 15
Document Has Been Signed on 05/11/2024 02:11 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/11/2024 at 12:02 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
,
, CA

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of 3 residents, R1 and R2 are missing TB clearance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
1
2
3
4
Administrator will ensure R1 and R2 obtain a TB clearance and submit a copy to the department by POC due date 5/17/24.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in last fire/emergency drill was conducted 4/6/23 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
1
2
3
4
Administrator will conduct an emergency drill at the facility and will certify to conduct one every quarter in writing, will submit a copy of log to the department by POC due date 5/17/24.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2024


LIC809 (FAS) - (06/04)
Page: 9 of 15
Document Has Been Signed on 05/11/2024 02:11 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/11/2024 at 12:02 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
,
, CA

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 3 residents were observed to have a bed rail in beds and there is no physician's order on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/17/2024
Plan of Correction
1
2
3
4
Administrator will obtain a physician's order for each bed rail for R1-R3 and will submit a copy to the department or will remove rails and submit a picture by POC due date 5/17/24.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2024


LIC809 (FAS) - (06/04)
Page: 10 of 15
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: PEACEFUL KINGDOM HOME CARE I
FACILITY NUMBER: 197610244
VISIT DATE: 05/11/2024
NARRATIVE
1
2
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4
5
6
7
8
9
10
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14
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16
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19
20
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Resident #1(R1) is missing TB test clearance, Resident #2(R2) is missing an admission agreement, physician's report, TB clearance, and Resident #3 (R3) has a diagnosis of dementia and physician report was last done on 2/22/22 and appraisal was last reviewed on 1/10/23. Hospice plan was not observed on file for (3) residents.

Administrator's file was not available for review. Per staff current administrator is Jose Hernandez, LPA observed administrator's certificate posted at the facility for Jose Hernandez #6064133740 exp. date: 11/4/24. Per staff he has been the administrator for the last 2 years and Victoria Paredes is no longer working with the facility. Administrator will contact Regional Office to notify of change of administrator and submit all required documentation for change of administrator by 5/17/24.

Three (3) staff files were reviewed, Staff #3(S3) was not associated to the facility at the time of visit day, date of employment is 5/10/24, and file is missing health screening, and TB clearance. Per staff, staff #4 (S4) relieves staff on days off and first aid/CPR training was not observed on file. Initial 40 hours of training were not observed for any of the staff, and there were 8 hours of training provided within the last 12 months to Staff #2(S2) and S4.

LPA reviewed Infection Control plan and requested a copy be submitted to the regional office by 5/13/24. Emergency Disaster Plan was reviewed 12/5/22. Last fire/emergency drill was conducted on 4/6/23. A copy of Liability Insurance was not able to be provided at the time of the visit, LPA requested a copy be submitted to the Regional Office by 5/13/24.

LPA interviewed 2 staff and 2 residents.

Deficiencies were noted during this visit per Title 22 Regulations.

Exit interview was conducted with Jaziel Mabuti and a copy of this report, LIC 809D, Technical Violations, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2024
LIC809 (FAS) - (06/04)
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