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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610244
Report Date: 04/15/2025
Date Signed: 04/15/2025 02:57:25 PM

Document Has Been Signed on 04/15/2025 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
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) 342-8738
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 4DATE:
04/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Starr Carver, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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At 9:45 AM, Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with the staff Jaizel Mabuti who granted access to the facility. The staff contacted the Licensee Starr Carver via telephone and LPA explained the purpose of the visit. The Licensee arrived shortly after. LPA and the Licensee conducted a physical plant tour and observed the following:

The facility is licensed to serve 6 residents over the age of 60 years old. Facility currently is serving (2) residents on hospice with an exception from the Regional Office. 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, an office, a kitchen, a front yard, and back yard.
Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA observed the kitchen to be clean with sufficient food for at least two (2) days of perishable and seven (7) days of non-perishable. In the refrigerator LPA observed molded bread, carrots with white growth on their skin, and moldy cabbage. LPA observed that the sharps are locked and inaccessible under the sink cabinet. LPA observed that the medication are locked in one of the kitchen cabinets and inaccessible to residents in care. A full fire extinguisher was observed hanging on the kitchen wall and last serviced on 12/5/2024.


Laundry: LPA observed laundry next to the kitchen and the washer and dryer in working condition. All laundry detergents and other cleaning supplies in the laundry room were locked and inaccessible to residents in care. LPA observed a cabinet with medications of residents and was unlocked and accessible to residents in care.
Continue on LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 04/15/2025
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Bedrooms: LPA observed five (5) Resident rooms were observed with sufficient lighting, the required furniture and bedding supplies. Room # (6) is observed to be shared. Room #(2) and room # (5) are vacant currently. Room #4 is currently being used as a staff room and LPA observed to be locked and inaccessible to residents in care.

Bathrooms: Three (3) Bathrooms were observed clean and in good repair. LPA observed a skid mat/strips in all three (3) bathrooms. Water temperature was tested and measured to be 118.0 degrees F.

Dining Room/Living room: Dining room was observed to be clean and contained one table with seating for six (6) residents. Living room was observed to be clean and free of hazards and has TV and furniture in good repair. The living room and dinning room has sufficient lighting. Nearby thermostat by the living room was observed to read 68-degree F.

Outside areas: LPA toured the outside area of the facility. LPA observed patio furniture in good repair. All walkways were clean and free from obstruction. All emergency exits were locked with latches from inside and could be easily opened. LPA observed cleaning spray outside by the laundry door accessible and unlocked to residents in care.

Smoke detectors/carbon monoxide/sound signals: 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.

Between 11:20 AM to 1:20 PM, LPA reviewed records of four (4) residents and three (3) staff. Residents and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

Deficiencies were issued during today’s visit. Appeal rights explained.

Exit interview conducted and copy of this report signed and delivered.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/15/2025 02:57 PM - It Cannot Be Edited


Created By: Huma Rahimi On 04/15/2025 at 01:17 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: 04/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(28)
87555(b)(28) General Food Service Requirements All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations the Licensee did not comply by having old/rotten perishable foods and molded bread in the refrigerator which poses a potential health and safety risk to the residents in care.
POC Due Date: 04/22/2025
Plan of Correction
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The Administrator has agreed to remove and discard the rotten foods from the refrigerator.
This part of the plan of correction met.
Train all staff on food service and discarding rotten foods. Submit to CCL the staff sign in sheet and training material.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/15/2025 02:57 PM - It Cannot Be Edited


Created By: Huma Rahimi On 04/15/2025 at 02:35 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: 04/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by leaving the medication cabinet in the laundry room open and accessible to residents in care and also leaving cleaning sprays in the back yard unlocked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2025
Plan of Correction
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Administrator agreed to schedule vendorized training for all staff and submit to CCL the vendor information and scheduled date of training for the medication. An in-service training will also be conducted and the proof will be submitted to CCL upon completion for both training.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2025


LIC809 (FAS) - (06/04)
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